MEDICARE: RICKY WILSON FERGUSON

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1861035610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICKY WILSON FERGUSON

Provider Business Mailing Address
First Line	:	4671 COUNTRY LN APT 108
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-5823
Country	:	US
Telephone Number	:	216-317-9703
Fax Number	:	440-822-3716

Provider Business Practice Location Address
First Line	:	4671 COUNTRY LN APT 108
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-5823
Country	:	US
Telephone Number	:	216-317-9703
Fax Number	:	440-822-3716

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

Provider Enumeration Date	:	10/24/2019
Last Update Date	:	10/24/2019

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