Healthcare Provider Details

I. General information

NPI: 1427402379
Provider Name (Legal Business Name): DIANE FERGUSON MED, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 BERRYWOOD DR STE 203
COLUMBIA MO
65201-6515
US

IV. Provider business mailing address

2885 W BATTLEFIELD ST STE 102
SPRINGFIELD MO
65807-3952
US

V. Phone/Fax

Practice location:
  • Phone: 573-777-8455
  • Fax:
Mailing address:
  • Phone: 417-849-7731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2015016662
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: