Provider Demographics
NPI:1336270990
Name:BOREY, MICHELE JEANNE (LOTR)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:JEANNE
Last Name:BOREY
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-6115
Mailing Address - Country:US
Mailing Address - Phone:985-785-7103
Mailing Address - Fax:
Practice Address - Street 1:151 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-6115
Practice Address - Country:US
Practice Address - Phone:985-785-7103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11835174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1315460Medicaid
LAOTT.Z11835OtherSTATE LICENSE