Provider Demographics
NPI:1285804328
Name:BORDEAUX, GORDON LEWIS
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:LEWIS
Last Name:BORDEAUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 KOALA DRIVE
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841
Mailing Address - Country:US
Mailing Address - Phone:509-826-6191
Mailing Address - Fax:509-826-8416
Practice Address - Street 1:1007 KOALA AVE
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9247
Practice Address - Country:US
Practice Address - Phone:509-826-6191
Practice Address - Fax:509-826-8416
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003406101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)