Provider Demographics
NPI:1619969748
Name:FERGUSON, MISTI L (PT)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:L
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:902 ILLINI DR
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-4700
Practice Address - Country:US
Practice Address - Phone:309-796-3450
Practice Address - Fax:309-796-3460
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013897225100000X
IA03722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-013897OtherILLINOIS PT LICENSE NO
IL1245373166OtherGROUP NPI NUMBER
IL1245373166OtherGROUP NPI NUMBER