Provider Demographics
NPI:1467044461
Name:FERGUSON, GWENDOLYN (LSW)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6796 CHARLES ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070
Mailing Address - Country:US
Mailing Address - Phone:440-724-9025
Mailing Address - Fax:
Practice Address - Street 1:10427 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102
Practice Address - Country:US
Practice Address - Phone:216-772-3415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1903645104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker