Provider Demographics
NPI:1992732705
Name:FERGUSON, PHYLLIS ANNETTE (LMSW LPC)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:ANNETTE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LMSW LPC
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:ANNETTE
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:441 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446
Mailing Address - Country:US
Mailing Address - Phone:810-664-4557
Mailing Address - Fax:810-664-5181
Practice Address - Street 1:441 CLAY ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446
Practice Address - Country:US
Practice Address - Phone:810-664-4557
Practice Address - Fax:810-664-5181
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001683101YP2500X
MI6801013350104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008927900OtherBLUE CROSS
MI170021OtherVALUE OPTIONS