=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003126145
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TASHAWNA FERGUSON OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2010
-----------------------------------------------------
Last Update Date | 10/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 LINDENWOOD ROAD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10308-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-356-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5636 BRIAR KNOLL COURT
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-595-7290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 016381-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------