MEDICARE: CRAIGRISON LEILAN FERGUSON

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1720670045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRAIGRISON LEILAN FERGUSON

Provider Business Mailing Address
First Line	:	1121 S DOUGLAS BLVD STE A
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-5210
Country	:	US
Telephone Number	:	405-582-3990
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 S DOUGLAS BLVD STE A
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-5210
Country	:	US
Telephone Number	:	405-582-3990
Fax Number	:

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

Provider Enumeration Date	:	02/08/2021
Last Update Date	:	12/03/2021

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