NPIMap

Individual provider Active NPI

Glenn Eugene Ferguson, PHD

  • Clinical Psychologist
  • Espanola, NM
National Provider Identifier
1922391994
Registry record updated Jul 8, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
PSY-2022-0061 Issued in NM
Practice address
206 S Coronado Ave
Espanola, NM 87532-2792
Phone
(860) 788-6404
NPI assigned
May 24, 2011
Last updated
Jul 8, 2024By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 8, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X PSY.0004552 CO
Clinical Psychologist 103TC0700X 44SI00428700 NJ
Clinical Psychologist 103TC0700X PSY-2022-0061 NM Primary

Addresses

Primary practice location

206 S Coronado Ave
Espanola, NM 87532-2792

Mailing address

PO Box 1595
Middletown, CT 06457-8095
Phone (860) 788-6404

Other practice location 1

1900 W Littleton Blvd
Littleton, CO 80120-2023
Phone (860) 788-6404

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NJ, CO, NM3 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
I20110630000539 NJ Practitioner - Clinical Psychologist 3870771496 Reassigns benefits to 1 organization
I20180430000328 CO Practitioner - Clinical Psychologist 3870771496 Reassigns benefits to 1 organization
I20230104001480 NM Practitioner - Clinical Psychologist 3870771496 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Clinical Psychologist
Education
Other, 1997
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Meditelecare of Colorado LLCGroup PAC ID 2567888993, 3 clinicians
Meditelecare of New Mexico, LLCGroup PAC ID 1254668122, 7 clinicians

Practice addresses (Care Compare)

1900 W Littleton Blvd
Littleton, CO 80120-2023
Phone (860) 788-6404

206 S Coronado Ave
Espanola, NM 87532-2792
Phone 8607886404152

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Philosophy

State licenses

LicenseStateTypeSpecialty
44SI00428700NJMDClinical Psychologist

Practice roles

OrganizationSpecialtyStatusNew patients
Meditelecare of Colorado LLC Clinical CurrentSince Jun 1, 2021 Accepting new patients
Meditelecare of New Mexico, LLC Clinical CurrentSince Sep 22, 2022 Accepting new patients
Meditelecare of New Jersey LLC Clinical CurrentSince Jun 1, 2021 Accepting new patients

Locations

1900 W Littleton Blvd
Littleton, CO 80120
Phone 41550438389238

206 S Coronado Ave
Espanola, NM 87532
Phone (616) 438-0737

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1306195200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1720396800000",
    "number": "1922391994",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1595",
            "city": "MIDDLETOWN",
            "state": "CT",
            "postal_code": "064578095",
            "telephone_number": "860-788-6404"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "206 S CORONADO AVE",
            "city": "ESPANOLA",
            "state": "NM",
            "postal_code": "875322792",
            "telephone_number": "860-788-6404"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1900 W Littleton Blvd",
            "address_purpose": "LOCATION",
            "city": "Littleton",
            "state": "CO",
            "postal_code": "801202023",
            "country_code": "US",
            "telephone_number": "860-788-6404",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FERGUSON",
        "first_name": "GLENN",
        "middle_name": "EUGENE",
        "credential": "PHD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-05-24",
        "last_updated": "2024-07-08",
        "certification_date": "2024-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CO",
            "license": "PSY.0004552",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NJ",
            "license": "44SI00428700",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NM",
            "license": "PSY-2022-0061",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Espanola, NM

Sources for this page

Verify at the official NPI Registry.