Basic Information
| Provider Information | |||||||||
| NPI: | 1275757411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | EDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 526 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256210526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046643922 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1609 W 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256613006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042350026 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LVN-164X00000X | WV | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.