Provider Demographics
NPI:1811051238
Name:BOURDEAU, TERI LEANN (PHD)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:LEANN
Last Name:BOURDEAU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-2705
Mailing Address - Country:US
Mailing Address - Phone:918-561-8383
Mailing Address - Fax:918-561-8546
Practice Address - Street 1:2345 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-2705
Practice Address - Country:US
Practice Address - Phone:918-561-8383
Practice Address - Fax:918-561-8546
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1009103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200078120AMedicaid