Provider Demographics
NPI:1629871447
Name:FERGUSON, TRACEY
Entity type:Individual
Prefix:
First Name:TRACEY
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 1:7860 E WESTLAKE DR
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-4898
Mailing Address - Country:US
Mailing Address - Phone:812-618-8573
Mailing Address - Fax:
Practice Address - Street 1:7860 E WESTLAKE DR
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-4898
Practice Address - Country:US
Practice Address - Phone:812-618-8573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.031329363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health