Provider Demographics
NPI:1770877425
Name:FERGUSON, MARLA (LCSW)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2610 KEN RAY DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-6118
Mailing Address - Country:US
Mailing Address - Phone:217-224-0557
Mailing Address - Fax:217-224-0557
Practice Address - Street 1:2610 KEN RAY DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-6118
Practice Address - Country:US
Practice Address - Phone:217-257-9170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-29
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110137741041C0700X
IL149.0170021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical