Healthcare Provider Details

I. General information

NPI: 1699039388
Provider Name (Legal Business Name): LYNN MARIE FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 LEE RD
FOLLANSBEE WV
26037-1783
US

IV. Provider business mailing address

840 LEE RD
FOLLANSBEE WV
26037-1783
US

V. Phone/Fax

Practice location:
  • Phone: 304-527-1100
  • Fax:
Mailing address:
  • Phone: 304-527-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberC1853
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: