Provider Demographics
NPI:1881192979
Name:FERGUSON-SMITH, MACY YVETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:YVETTE
Last Name:FERGUSON-SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4096
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:217-277-2253
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4096
Practice Address - Country:US
Practice Address - Phone:217-592-0413
Practice Address - Fax:217-277-2253
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150102867104100000X
IL1490211071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150102867OtherSTATE OF ILLINOIS