MEDICARE: MR. WILDA ELAINE FERGUNSON MA

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1790912996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILDA ELAINE FERGUNSON MA

Provider Business Mailing Address
First Line	:	3450 BROAD ST STE 104
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7214
Country	:	US
Telephone Number	:	805-762-4472
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 BROAD ST STE 104
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7214
Country	:	US
Telephone Number	:	805-762-4472
Fax Number	:

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

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	06/15/2009

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