Provider Demographics
NPI:1679298491
Name:CHRISTINE ADALINE FERGUSON LSW, LICDC LLC
Entity Type:Organization
Organization Name:CHRISTINE ADALINE FERGUSON LSW, LICDC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:216-727-6410
Mailing Address - Street 1:18320 MAPLEBORO AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-2768
Mailing Address - Country:US
Mailing Address - Phone:216-727-6410
Mailing Address - Fax:
Practice Address - Street 1:16360 BROADWAY AVE STE B101
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-2573
Practice Address - Country:US
Practice Address - Phone:216-510-7170
Practice Address - Fax:216-510-7213
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHRISTINE ADALINE FERGUSON, LSW-LICDC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children