Provider Demographics
NPI:1457959777
Name:FERGUSON, SHANNON WHITE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:WHITE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:309 FARMCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4185
Mailing Address - Country:US
Mailing Address - Phone:860-606-4820
Mailing Address - Fax:
Practice Address - Street 1:35 COLD SPRING RD
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-3160
Practice Address - Country:US
Practice Address - Phone:518-209-1727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085109104100000X
CT004405104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker