MEDICARE: MS. SANDRA KAY 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		IL

General Provider Information

NPI Number	:	1538157961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA KAY FERGUSON LCSW

Provider Business Mailing Address
First Line	:	2506 GALEN DR
Second Line	:	SUITE 103
City	:	CHAMPAIGN
State	:	IL
Zip	:	61821-7046
Country	:	US
Telephone Number	:	217-398-0744
Fax Number	:	217-398-0778

Provider Business Practice Location Address
First Line	:	2506 GALEN DR
Second Line	:	SUITE 103
City	:	CHAMPAIGN
State	:	IL
Zip	:	61821-7046
Country	:	US
Telephone Number	:	217-398-0744
Fax Number	:	217-398-0778

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

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	07/08/2007

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