Healthcare Provider Details

I. General information

NPI: 1710507629
Provider Name (Legal Business Name): TIMOTHY FERGUSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 5TH ST
BROOKINGS OR
97415-9199
US

IV. Provider business mailing address

615 5TH ST
BROOKINGS OR
97415-9199
US

V. Phone/Fax

Practice location:
  • Phone: 541-708-9581
  • Fax:
Mailing address:
  • Phone: 541-708-9581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: