Provider Demographics
NPI:1699275222
Name:FERGUSON, TRACI (DPT)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 ORANGE GROVE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2334
Mailing Address - Country:US
Mailing Address - Phone:858-692-1245
Mailing Address - Fax:
Practice Address - Street 1:1965 HILLHURST AVE FL 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2711
Practice Address - Country:US
Practice Address - Phone:323-912-9166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT294359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist