Provider Demographics
NPI:1215019294
Name:FERGUSON, MARDENE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARDENE
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 E COUGAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7343
Mailing Address - Country:US
Mailing Address - Phone:208-887-6809
Mailing Address - Fax:
Practice Address - Street 1:10740 W FAIRVIEW AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-7926
Practice Address - Country:US
Practice Address - Phone:208-376-0191
Practice Address - Fax:208-658-6299
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-10711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical