Basic Information
| Provider Information | |||||||||
| NPI: | 1679629042 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.C.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DECORTE | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | KATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | L.C.S.W. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 6TH AVE S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277676706 | ||||||||
| FaxNumber: | 7277674715 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 6TH AVE S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277676706 | ||||||||
| FaxNumber: | 7277674715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW 4576 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | SW-4576 | FL | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 811642300 | 05 | FL | MEDICAID | 753023400 | 05 | FL | MEDICAID |