Provider Demographics
NPI:1679616676
Name:BORDIN, CARLA
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:BORDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W BRANDON BLVD
Mailing Address - Street 2:#106
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-4630
Practice Address - Country:US
Practice Address - Phone:813-689-8828
Practice Address - Fax:813-689-8802
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767765100Medicaid