Provider Demographics
NPI:1407677941
Name:FERGUSON, CARLTON EDWARD (CADC #31124)
Entity type:Individual
Prefix:
First Name:CARLTON
Middle Name:EDWARD
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:CADC #31124
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 W MARQUETTE RD APT 1A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-2765
Mailing Address - Country:US
Mailing Address - Phone:312-343-8952
Mailing Address - Fax:
Practice Address - Street 1:614 W MARQUETTE RD APT 1A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2765
Practice Address - Country:US
Practice Address - Phone:312-343-8952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL31124101YP2500X, 106H00000X, 171M00000X, 172V00000X, 175T00000X, 302F00000X, 305S00000X, 405300000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
No405300000XOther Service ProvidersPrevention Professional