Provider Demographics
NPI:1801117270
Name:BOURDA, BETTINA (OTR/L, CLT)
Entity type:Individual
Prefix:
First Name:BETTINA
Middle Name:
Last Name:BOURDA
Suffix:
Gender:F
Credentials:OTR/L, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 WISCONSIN AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:407-219-4367
Practice Address - Street 1:424 E CENTRAL BLVD
Practice Address - Street 2:STE 378
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-1923
Practice Address - Country:US
Practice Address - Phone:407-219-4367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112621225X00000X
FL14270225X00000X
IL056011398225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist