Healthcare Provider Details

I. General information

NPI: 1609542760
Provider Name (Legal Business Name): MARK RYAN FERGUSON LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RYAN FERGUSON

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 COLUMBUS RD
ATHENS OH
45701-1315
US

IV. Provider business mailing address

PO BOX 188
CHILLICOTHEE OH
45601-0188
US

V. Phone/Fax

Practice location:
  • Phone: 740-249-4318
  • Fax: 740-249-4330
Mailing address:
  • Phone: 740-773-4366
  • Fax: 740-773-4750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2405863
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: