Provider Demographics
NPI:1730192501
Name:BORDELON, TAMARA L (PT)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:L
Last Name:BORDELON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST STE 355
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7363
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:1325 LOUISVILLE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6021
Practice Address - Country:US
Practice Address - Phone:318-807-1500
Practice Address - Fax:318-807-1504
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA104370500OtherFED EMP W/C
LA2387146Medicaid
LA408228YJBUMedicare PIN