Provider Demographics
NPI:1902019854
Name:BORDELON, AMY L (PT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:L
Last Name:BORDELON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 SOUTH CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70130
Mailing Address - Country:US
Mailing Address - Phone:504-508-4425
Mailing Address - Fax:
Practice Address - Street 1:2005 SOUTH CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130
Practice Address - Country:US
Practice Address - Phone:504-508-4425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist