Healthcare Provider Details

I. General information

NPI: 1760479638
Provider Name (Legal Business Name): BETTY FERGUSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 E SEVIER ST
BENTON AR
72015-3934
US

IV. Provider business mailing address

110 PEARSON
BENTON AR
72015-4436
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-4224
  • Fax: 501-776-0411
Mailing address:
  • Phone: 501-315-4224
  • Fax: 501-778-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1235-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: