Provider Demographics
NPI:1073679452
Name:FERGUSON, SUSAN AMANDA (SLP)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:AMANDA
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37440
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-7440
Mailing Address - Country:US
Mailing Address - Phone:505-889-3412
Mailing Address - Fax:505-889-3422
Practice Address - Street 1:5321 MENAUL BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3127
Practice Address - Country:US
Practice Address - Phone:505-889-3412
Practice Address - Fax:505-889-3422
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51332311Medicaid