Provider Demographics
NPI:1053679480
Name:FERGUSON, MICHELLE (CCLS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:CCLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 900
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-0900
Mailing Address - Country:US
Mailing Address - Phone:845-765-0463
Mailing Address - Fax:516-706-1418
Practice Address - Street 1:2004 LYNDHURST WAY
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-7159
Practice Address - Country:US
Practice Address - Phone:845-765-0463
Practice Address - Fax:516-706-1418
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21725103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst