Healthcare Provider Details

I. General information

NPI: 1609109354
Provider Name (Legal Business Name): TIA FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12430 ASHCROFT DR
HOUSTON TX
77035-5406
US

IV. Provider business mailing address

12430 ASHCROFT DR
HOUSTON TX
77035-5406
US

V. Phone/Fax

Practice location:
  • Phone: 713-729-8535
  • Fax: 713-729-8535
Mailing address:
  • Phone: 713-729-8535
  • Fax: 713-729-8535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: