1396678876 NPI number — MS. SIMONE VENISSA FERGUSON LMSW

Table of content: MS. SIMONE VENISSA FERGUSON LMSW (NPI 1396678876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396678876 NPI number — MS. SIMONE VENISSA FERGUSON LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
SIMONE
Provider Middle Name:
VENISSA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396678876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2003 FIVE OAKS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCKER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30084-8152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-706-7039
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3430 HIGHWAY 20 SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30013-2868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-922-4482
Provider Business Practice Location Address Fax Number:
770-922-4640
Provider Enumeration Date:
06/04/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  MSW012322 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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