MEDICARE: JOHN FERGUSON LICSW LLC

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

General Provider Information

NPI Number	:	1467696872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN FERGUSON LICSW LLC

Provider Business Mailing Address
First Line	:	1340 81ST AVE NE
Second Line	:
City	:	SPRING LAKE PARK
State	:	MN
Zip	:	55432-2116
Country	:	US
Telephone Number	:	763-783-4528
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 81ST AVE NE
Second Line	:
City	:	SPRING LAKE PARK
State	:	MN
Zip	:	55432-2116
Country	:	US
Telephone Number	:	763-783-4528
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN FERGUSON
Credential	:
Telephone Number	:	763-783-4528

Provider Enumeration Date	:	04/29/2009
Last Update Date	:	04/29/2009

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