Provider Demographics
NPI:1992784045
Name:BORDELON, WILLIAM GLENN (MA, LPC, LMFT)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:GLENN
Last Name:BORDELON
Suffix:
Gender:M
Credentials:MA, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 28 RD
Mailing Address - Street 2:STE B209
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6556
Mailing Address - Country:US
Mailing Address - Phone:970-245-3212
Mailing Address - Fax:970-245-3216
Practice Address - Street 1:518 28 RD
Practice Address - Street 2:STE B209
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6556
Practice Address - Country:US
Practice Address - Phone:970-245-3212
Practice Address - Fax:970-245-3216
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO649106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC804632Medicare PIN