Basic Information
| Provider Information | |||||||||
| NPI: | 1861879355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W., L.C.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 902 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628962210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189376483 | ||||||||
| FaxNumber: | 6189371440 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 EDWARDS ST | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184622331 | ||||||||
| FaxNumber: | 6184627160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2015 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149.017581 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 376000405 | 05 | IL | MEDICAID |