Healthcare Provider Details

I. General information

NPI: 1902367832
Provider Name (Legal Business Name): EBONE FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7464 EXCHANGE PL
BATON ROUGE LA
70806-1519
US

IV. Provider business mailing address

4000 MCHUGH RD UNIT 56
ZACHARY LA
70791-5361
US

V. Phone/Fax

Practice location:
  • Phone: 225-831-4998
  • Fax:
Mailing address:
  • Phone: 225-301-2619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number15207
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: