Provider Demographics
NPI:1346724176
Name:FERGUSON, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 SAVANNAH ST
Mailing Address - Street 2:
Mailing Address - City:MOUND CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64470-1539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 SAVANNAH ST
Practice Address - Street 2:
Practice Address - City:MOUND CITY
Practice Address - State:MO
Practice Address - Zip Code:64470-1539
Practice Address - Country:US
Practice Address - Phone:402-301-9885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60868468225100000X
IA005225225100000X
MO2005005090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist