=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679921043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA FERGUSON PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2016
-----------------------------------------------------
Last Update Date | 10/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10300 BUSHMAN DR #300
-----------------------------------------------------
City | OAKTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22124-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-705-2922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2961A HUNTER MILL RD # 642
-----------------------------------------------------
City | OAKTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22124-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-543-5107
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071005928
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810005238
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------