Provider Demographics
NPI:1063865327
Name:FERGUSON, LAUREN MAXON (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MAXON
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5021
Mailing Address - Country:US
Mailing Address - Phone:630-750-0854
Mailing Address - Fax:
Practice Address - Street 1:3450 LACEY RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5430
Practice Address - Country:US
Practice Address - Phone:630-743-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400336044Medicare PIN