Provider Demographics
NPI:1184674046
Name:FERNEYHOUGH, STANLEY CARL (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:CARL
Last Name:FERNEYHOUGH
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LAKE ST N
Mailing Address - Street 2:SUITE 320
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2523
Mailing Address - Country:US
Mailing Address - Phone:651-464-6900
Mailing Address - Fax:
Practice Address - Street 1:220 N 6TH AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1952
Practice Address - Country:US
Practice Address - Phone:218-249-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN431250300Medicaid