=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346399490
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE W FERGUSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2007
-----------------------------------------------------
Last Update Date | 03/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420A W WALNUT ST
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40422-1836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-936-9474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 HERRINGTON WOODS
-----------------------------------------------------
City | HARRODSBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40330-9796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-748-5613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 600
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------