Provider Demographics
NPI:1881002251
Name:FERGUSON, ELISABETH
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 KENSINGTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 KENSINGTON RD
Practice Address - Street 2:SUITE 201
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2143
Practice Address - Country:US
Practice Address - Phone:815-761-2945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000617043103TS0200X
IL1802098103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool