Provider Demographics
NPI:1164803763
Name:FERGUSON, BRENDA YVONNE
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:YVONNE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:BRENDA
Other - Middle Name:YVONNE
Other - Last Name:DORSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:468 WEYANOKE DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-7080
Mailing Address - Country:US
Mailing Address - Phone:706-860-2959
Mailing Address - Fax:
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW006253104100000X
SC10461104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker