Provider Demographics
NPI:1801142732
Name:BORDEAUX, ANDREW RUSSELL (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:RUSSELL
Last Name:BORDEAUX
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-0504
Mailing Address - Country:US
Mailing Address - Phone:414-617-2696
Mailing Address - Fax:
Practice Address - Street 1:1624 BARTON AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090
Practice Address - Country:US
Practice Address - Phone:414-368-0449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3708-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist