Provider Demographics
NPI:1083710719
Name:WASHINGTON, FERMOND LEON (OT)
Entity Type:Individual
Prefix:MR
First Name:FERMOND
Middle Name:LEON
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 OLD BULLARD RD
Mailing Address - Street 2:#S-27
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3631
Mailing Address - Country:US
Mailing Address - Phone:903-962-7901
Mailing Address - Fax:903-962-3082
Practice Address - Street 1:5609 DONNYBROOK AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6111
Practice Address - Country:US
Practice Address - Phone:903-962-7901
Practice Address - Fax:903-962-3082
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104577225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82031OtherBLUE CROSS BLUE LINK NUMB
TX8T4231OtherBLUE CROSS PAR PLAN