Healthcare Provider Details

I. General information

NPI: 1255781902
Provider Name (Legal Business Name): MICHAEL WAYNE FERGUSON JR. LCSW, LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 TACKETT FARMS RD
SMYRNA GA
30082-3918
US

IV. Provider business mailing address

504 TACKETT FARMS RD
SMYRNA GA
30082-3918
US

V. Phone/Fax

Practice location:
  • Phone: 980-312-4166
  • Fax:
Mailing address:
  • Phone: 980-312-4166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-155236
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009914
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-19807
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: