Provider Demographics
NPI:1215568654
Name:FERGUSON, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S. WALNUT ST.
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5918
Mailing Address - Country:US
Mailing Address - Phone:920-832-5270
Mailing Address - Fax:920-832-2185
Practice Address - Street 1:320 S. WALNUT ST.
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5918
Practice Address - Country:US
Practice Address - Phone:920-832-5270
Practice Address - Fax:920-832-2185
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131949-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical