Provider Demographics
NPI:1588631279
Name:FERNSTROM, CARROLL (OT)
Entity Type:Individual
Prefix:
First Name:CARROLL
Middle Name:
Last Name:FERNSTROM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:926 WILLIAMSON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2308
Mailing Address - Country:US
Mailing Address - Phone:919-696-6691
Mailing Address - Fax:919-846-6767
Practice Address - Street 1:926 WILLIAMSON DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-2308
Practice Address - Country:US
Practice Address - Phone:919-696-6691
Practice Address - Fax:919-846-6767
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0315225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ38337AOtherMEDICARE PTAN
NC562132986OtherTAX ID
NCP00021102OtherRAILROAD
NC1321MOtherBCBS
NC2510811-AOtherMEDICARE PTAN
NC7301597Medicaid