Provider Demographics
NPI:1275730863
Name:FERGUSON, ANNE MARIE (MPT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:MARIE
Other - Last Name:GAUTHIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2501 N WAYNE AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2177
Mailing Address - Country:US
Mailing Address - Phone:312-480-7433
Mailing Address - Fax:312-610-5655
Practice Address - Street 1:3180 MIDLANE DR
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:IL
Practice Address - Zip Code:60083-9529
Practice Address - Country:US
Practice Address - Phone:847-513-1443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12285895OtherCAQH PROVIDER ID
CA12285895OtherCAQH PROVIDER ID