Basic Information
| Provider Information | |||||||||
| NPI: | 1821122391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | WADE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSW, QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11035 NE SANDY BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972202553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412218681 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1507 NE 122ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972301911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032584228 | ||||||||
| FaxNumber: | 5034932656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.