=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578170965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH FERGUSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2020
-----------------------------------------------------
Last Update Date | 09/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 183 MONTOWESE ST STE G
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-3869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-513-9562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 SPRING ROCK RD
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-5519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-823-8148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 003695
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------