Provider Demographics
NPI:1457688749
Name:FERGUSON, MELINDA (PT)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:L
Other - Last Name:HOLLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:105 WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-1447
Mailing Address - Country:US
Mailing Address - Phone:859-421-4785
Mailing Address - Fax:
Practice Address - Street 1:700 BIRCH LN
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2275
Practice Address - Country:US
Practice Address - Phone:573-774-6456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-08
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36160225100000X
TX1254590225100000X
MO2018032589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist