Provider Demographics
NPI:1881704955
Name:FERGUSON, LORA MICHELLE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:MICHELLE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 S AVENUE G
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6717
Mailing Address - Country:US
Mailing Address - Phone:575-309-8710
Mailing Address - Fax:
Practice Address - Street 1:1500 S AVE K
Practice Address - Street 2:STATION 17
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-7400
Practice Address - Country:US
Practice Address - Phone:575-562-4174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4292255A2300X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer