Provider Demographics
NPI:1073660569
Name:FERGUSON, ANGELA MARIE (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:FERGUSON
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 1:1615 W WALLEN AVE
Mailing Address - Street 2:#1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4586
Mailing Address - Country:US
Mailing Address - Phone:773-368-6674
Mailing Address - Fax:847-317-8056
Practice Address - Street 1:2065 HALF DAY RD
Practice Address - Street 2:
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1241
Practice Address - Country:US
Practice Address - Phone:847-317-7116
Practice Address - Fax:847-317-8056
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer