Provider Demographics
NPI:1790912996
Name:FERGUNSON, WILDA ELAINE (MA)
Entity Type:Individual
Prefix:MR
First Name:WILDA
Middle Name:ELAINE
Last Name:FERGUNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 BROAD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7214
Mailing Address - Country:US
Mailing Address - Phone:805-762-4472
Mailing Address - Fax:
Practice Address - Street 1:3450 BROAD ST STE 104
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7214
Practice Address - Country:US
Practice Address - Phone:805-762-4472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor