Provider Demographics
NPI:1922364132
Name:FERGUSON, WANDA LISA (COTA/L)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LISA
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 TROY HAWK RUN HWY
Mailing Address - Street 2:
Mailing Address - City:PHILIPSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16866-7922
Mailing Address - Country:US
Mailing Address - Phone:814-553-1659
Mailing Address - Fax:
Practice Address - Street 1:100 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-1982
Practice Address - Country:US
Practice Address - Phone:814-342-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007296224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant