Provider Demographics
NPI:1629313549
Name:FERGUSON, STEPHANIE JANE (PTA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JANE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 NOAH BLEDSOE RD
Mailing Address - Street 2:
Mailing Address - City:SMITHS GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42171-8275
Mailing Address - Country:US
Mailing Address - Phone:270-597-9759
Mailing Address - Fax:
Practice Address - Street 1:813 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42210-9009
Practice Address - Country:US
Practice Address - Phone:270-597-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02317225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant