Provider Demographics
NPI:1750534632
Name:BORDEAUX, MARTA ELIZABETH
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:ELIZABETH
Last Name:BORDEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTA
Other - Middle Name:ELIZABETH
Other - Last Name:ROOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:971 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2503
Mailing Address - Country:US
Mailing Address - Phone:360-423-6140
Mailing Address - Fax:360-423-1405
Practice Address - Street 1:971 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2503
Practice Address - Country:US
Practice Address - Phone:360-423-6140
Practice Address - Fax:360-423-1405
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X
WA60967434101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No372600000XNursing Service Related ProvidersAdult Companion