Provider Demographics
NPI:1457951998
Name:FERGUSON, PERI MCKENZIE
Entity type:Individual
Prefix:
First Name:PERI
Middle Name:MCKENZIE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PERI
Other - Middle Name:MCKENZIE
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2194 HERITAGE LN N
Mailing Address - Street 2:
Mailing Address - City:NORTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1779
Mailing Address - Country:US
Mailing Address - Phone:619-616-0190
Mailing Address - Fax:
Practice Address - Street 1:6300 W OLD SHAKOPEE RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-2654
Practice Address - Country:US
Practice Address - Phone:507-353-3083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other