Provider Demographics
NPI:1679534556
Name:FERGUSON, LAURIE KATHRYN (PHD, LCSW, LMFT)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:KATHRYN
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PHD, LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S WASHINGTON ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4343
Mailing Address - Country:US
Mailing Address - Phone:920-437-7884
Mailing Address - Fax:920-884-0005
Practice Address - Street 1:200 S WASHINGTON ST
Practice Address - Street 2:SUITE 306
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4343
Practice Address - Country:US
Practice Address - Phone:920-437-7884
Practice Address - Fax:920-884-0005
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39071041C0700X
WI196106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39619600Medicaid