Provider Demographics
NPI:1740642412
Name:BORDELON, AMY KATHRYN (LMFT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KATHRYN
Last Name:BORDELON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 SW UPPER TERRACE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1560
Mailing Address - Country:US
Mailing Address - Phone:303-880-0287
Mailing Address - Fax:
Practice Address - Street 1:371 SW UPPER TERRACE DR STE 3
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1560
Practice Address - Country:US
Practice Address - Phone:303-880-0287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
ORT1136106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist