Provider Demographics
NPI:1922391994
Name:FERGUSON, GLENN EUGENE (PHD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:EUGENE
Last Name:FERGUSON
Suffix:
Gender:M
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:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-8095
Mailing Address - Country:US
Mailing Address - Phone:860-788-6404
Mailing Address - Fax:
Practice Address - Street 1:206 S CORONADO AVE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2792
Practice Address - Country:US
Practice Address - Phone:860-788-6404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004552103TC0700X
NJ44SI00428700103TC0700X
NMPSY-2022-0061103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical