Healthcare Provider Details

I. General information

NPI: 1184674046
Provider Name (Legal Business Name): STANLEY CARL FERNEYHOUGH PHD, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 03/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N 6TH AVE E
DULUTH MN
55805-1952
US

IV. Provider business mailing address

20 LAKE ST N SUITE 320
FOREST LAKE MN
55025-2523
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-7000
  • Fax:
Mailing address:
  • Phone: 651-464-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: