Basic Information
| Provider Information | |||||||||
| NPI: | 1457367377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW | ||||||||
| Address2: | STE 220 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539852733 | ||||||||
| FaxNumber: | 2539852868 | ||||||||
| Practice Location | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW | ||||||||
| Address2: | STE 220 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539852733 | ||||||||
| FaxNumber: | 2539852868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 02/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00001089 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8420549 | 05 | WA | MEDICAID | 0195036 | 01 | WA | L & I | OTHER | 8904774 | 01 | WA | CRIME VICTIMS | OTHER |