Provider Demographics
NPI:1619264157
Name:BORDELON, MALISSA M (LMT)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:M
Last Name:BORDELON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8864
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-8864
Mailing Address - Country:US
Mailing Address - Phone:228-223-7400
Mailing Address - Fax:
Practice Address - Street 1:7198 BEATLINE RD
Practice Address - Street 2:SUITE A
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-9146
Practice Address - Country:US
Practice Address - Phone:228-868-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1861225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist