MEDICARE: JOHN DWIGHT FERGUSON LICSW

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	10199	MN

General Provider Information

NPI Number	:	1588744304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN DWIGHT FERGUSON LICSW

Provider Business Mailing Address
First Line	:	5648 NEWTON AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-1531
Country	:	US
Telephone Number	:	612-922-2993
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	:	763-786-9729

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	07/08/2007

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