Provider Demographics
NPI:1225184468
Name:FURGUESON, CORNELIUS (PHD)
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:
Last Name:FURGUESON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 BAINBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1430
Mailing Address - Country:US
Mailing Address - Phone:215-868-5160
Mailing Address - Fax:215-546-9564
Practice Address - Street 1:1801 VINE ST
Practice Address - Street 2:ROOM 149-MG
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-1117
Practice Address - Country:US
Practice Address - Phone:215-868-5160
Practice Address - Fax:215-546-9564
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-008444-L103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist