Healthcare Provider Details

I. General information

NPI: 1659332393
Provider Name (Legal Business Name): DAVID ROY FERGUSON LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 S MAIN ST
RIGGINS ID
83549-9700
US

IV. Provider business mailing address

954 SLATE CREEK RD
WHITE BIRD ID
83554-5040
US

V. Phone/Fax

Practice location:
  • Phone: 208-484-4609
  • Fax: 208-345-3502
Mailing address:
  • Phone: 208-484-4609
  • Fax: 208-467-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC245
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: