Provider Demographics
NPI:1194192971
Name:FERGUSON, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 SOLIMAR WAY
Mailing Address - Street 2:NONE
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1421
Mailing Address - Country:US
Mailing Address - Phone:850-226-1246
Mailing Address - Fax:
Practice Address - Street 1:348 MIRACLE STRIP PKWY SW
Practice Address - Street 2:SUITE B-3
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5200
Practice Address - Country:US
Practice Address - Phone:850-862-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3055106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist