Healthcare Provider Details

I. General information

NPI: 1851834477
Provider Name (Legal Business Name): TAWNI MARIE FERGUSON QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 NE DEVILS LAKE BLVD SUITE 203
LINCOLN CITY OR
97367-5000
US

IV. Provider business mailing address

2717 NW JETTY AVE
LINCOLN CITY OR
97367-4342
US

V. Phone/Fax

Practice location:
  • Phone: 541-265-4196
  • Fax: 541-994-1882
Mailing address:
  • Phone: 801-889-9822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: