Healthcare Provider Details

I. General information

NPI: 1619222387
Provider Name (Legal Business Name): SOPHIA MARIE FERGUSON LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12270 POTOMAC VIEW DR
NEWBURG MD
20664-2250
US

IV. Provider business mailing address

12270 POTOMAC VIEW DR
NEWBURG MD
20664-2250
US

V. Phone/Fax

Practice location:
  • Phone: 301-641-4790
  • Fax:
Mailing address:
  • Phone: 301-641-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number30464
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: