MEDICARE: LORNETA HALL FERGUSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	5655807-3501	UT

General Provider Information

NPI Number	:	1265749154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORNETA HALL FERGUSON LCSW

Provider Business Mailing Address
First Line	:	P.O. BOX 790099
Second Line	:	633 EAST HIGHWAY 9
City	:	VIRGIN
State	:	UT
Zip	:	84779
Country	:	US
Telephone Number	:	435-635-5260
Fax Number	:	435-635-5327

Provider Business Practice Location Address
First Line	:	633 E HWY 9
Second Line	:
City	:	VIRGIN
State	:	UT
Zip	:	84779
Country	:	US
Telephone Number	:	435-635-4080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2010
Last Update Date	:	09/13/2010

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