Provider Demographics
NPI:1437602307
Name:FOUGEROUSSE, CASEY (MS, ATC)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:FOUGEROUSSE
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11694 W STATE ROAD 48
Mailing Address - Street 2:
Mailing Address - City:JASONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47438-6258
Mailing Address - Country:US
Mailing Address - Phone:812-798-2920
Mailing Address - Fax:
Practice Address - Street 1:2200 169TH ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46323-2068
Practice Address - Country:US
Practice Address - Phone:812-798-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002431A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer