Healthcare Provider Details

I. General information

NPI: 1457631772
Provider Name (Legal Business Name): NELSON LAWRENCE FERGUSON MFT INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E 17TH ST
SANTA ANA CA
92705-8521
US

IV. Provider business mailing address

3330 TOPAZ LN APT C1
FULLERTON CA
92831-2624
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-0400
  • Fax:
Mailing address:
  • Phone: 714-953-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: