Healthcare Provider Details

I. General information

NPI: 1891245098
Provider Name (Legal Business Name): CARRIE ELIZABETH FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARRIE ELIZABETH OBERG

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 JUDGE FRAN JAMIESON WAY
VIERA FL
32940-5998
US

IV. Provider business mailing address

PO BOX 781577
ORLANDO FL
32878-1577
US

V. Phone/Fax

Practice location:
  • Phone: 321-634-3688
  • Fax: 321-504-0955
Mailing address:
  • Phone: 321-961-3489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: