Provider Demographics
NPI:1801394812
Name:BOURDON, LIZA (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:BOURDON
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:NEWFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14867-9249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:89 MADISON ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1712
Practice Address - Country:US
Practice Address - Phone:607-758-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022062225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist