Provider Demographics
NPI:1982333969
Name:FERGUSON, MARY WIMSATT (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WIMSATT
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 W GLEN OAKS LN STE 166
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3371
Mailing Address - Country:US
Mailing Address - Phone:262-622-6353
Mailing Address - Fax:
Practice Address - Street 1:1017 W GLEN OAKS LN STE 166
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3371
Practice Address - Country:US
Practice Address - Phone:262-622-6353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3513-57103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling