Provider Demographics
NPI:1255765012
Name:FOUGEROUSSE, SARAH ROSE (MT)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ROSE
Last Name:FOUGEROUSSE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13295 ILLINOIS ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13295 ILLINOIS ST
Practice Address - Street 2:SUITE 310
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3019
Practice Address - Country:US
Practice Address - Phone:317-549-5047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20901112225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist