MEDICARE: CAROLYN 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	235Z00000X	Speech-Language Pathologist	146006087	IL

General Provider Information

NPI Number	:	1871720961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN FERGUSON

Provider Business Mailing Address
First Line	:	4136 GRAND AVENUE
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558
Country	:	US
Telephone Number	:	708-505-4364
Fax Number	:

Provider Business Practice Location Address
First Line	:	4136 GRAND AVE
Second Line	:
City	:	WESTERN SPRINGS
State	:	IL
Zip	:	60558-1432
Country	:	US
Telephone Number	:	708-505-4364
Fax Number	:

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

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	06/16/2009

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Directions to “ CAROLYN FERGUSON ” Practice Location

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