Healthcare Provider Details

I. General information

NPI: 1922391994
Provider Name (Legal Business Name): GLENN EUGENE FERGUSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S CORONADO AVE
ESPANOLA NM
87532-2792
US

IV. Provider business mailing address

PO BOX 1595
MIDDLETOWN CT
06457-8095
US

V. Phone/Fax

Practice location:
  • Phone: 860-788-6404
  • Fax:
Mailing address:
  • Phone: 860-788-6404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0004552
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number44SI00428700
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-2022-0061
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: