Provider Demographics
NPI:1720472574
Name:FERGUSON, STEPHANIE MARIE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 JEWELERS PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3893
Mailing Address - Country:US
Mailing Address - Phone:920-486-6595
Mailing Address - Fax:920-486-6013
Practice Address - Street 1:40 JEWELERS PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-3893
Practice Address - Country:US
Practice Address - Phone:920-486-6595
Practice Address - Fax:920-486-6013
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6458-125101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100049235Medicaid