MEDICARE: MRS. ELIZABETH ANN FERGUSON L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW 10893	FL

General Provider Information

NPI Number	:	1427476068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH ANN FERGUSON L.C.S.W.

Provider Business Mailing Address
First Line	:	1635 S RIDGEWOOD AVE STE 225
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-8478
Country	:	US
Telephone Number	:	386-788-5021
Fax Number	:	386-788-5021

Provider Business Practice Location Address
First Line	:	1635 S RIDGEWOOD AVE STE 225
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-8478
Country	:	US
Telephone Number	:	386-788-5021
Fax Number	:	386-788-5021

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2014
Last Update Date	:	11/20/2017

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