Provider Demographics
NPI:1669677431
Name:BORDELON, TERRI L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:L
Last Name:BORDELON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:WETHERINGTON
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1941
Mailing Address - Street 2:214 N CURRAN SUITE A
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466
Mailing Address - Country:US
Mailing Address - Phone:601-798-7820
Mailing Address - Fax:601-798-7820
Practice Address - Street 1:214 N CURRAN
Practice Address - Street 2:SUITE A
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466
Practice Address - Country:US
Practice Address - Phone:601-798-7820
Practice Address - Fax:601-798-7820
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC57501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09882008Medicaid
MS800000276Medicare PIN