Provider Demographics
NPI:1720792575
Name:FERGUSON, MICHAEL (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2649 N ARROYO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2649 N ARROYO DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6112
Practice Address - Country:US
Practice Address - Phone:570-573-4397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSLP1001418235Z00000X
CA1834075235Z00000X
CA29324235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist