Provider Demographics
NPI:1922391994
Name:FERGUSON, GLENN EUGENE (PHD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EUGENE
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MONTEBELLO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1366
Mailing Address - Country:US
Mailing Address - Phone:719-545-2746
Mailing Address - Fax:719-542-9638
Practice Address - Street 1:1012 W ABRIENDO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1128
Practice Address - Country:US
Practice Address - Phone:719-583-2207
Practice Address - Fax:719-542-9638
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004552103TC0700X
NJ44SI00428700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical