Healthcare Provider Details

I. General information

NPI: 1407677941
Provider Name (Legal Business Name): CARLTON EDWARD FERGUSON CADC #31124
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 W MARQUETTE RD APT 1A
CHICAGO IL
60621-2765
US

IV. Provider business mailing address

614 W MARQUETTE RD APT 1A
CHICAGO IL
60621-2765
US

V. Phone/Fax

Practice location:
  • Phone: 312-343-8952
  • Fax:
Mailing address:
  • Phone: 312-343-8952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number31124
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number31124
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number31124
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number31124
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number31124
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number31124
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number31124
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number31124
License Number StateIL
# 9
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number31124
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: