Healthcare Provider Details

I. General information

NPI: 1275757411
Provider Name (Legal Business Name): TERESA LYNN FERGUSON EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 3RD AVE
WILLIAMSON WV
25661-3006
US

IV. Provider business mailing address

PO BOX 526
GILBERT WV
25621-0526
US

V. Phone/Fax

Practice location:
  • Phone: 304-235-0026
  • Fax:
Mailing address:
  • Phone: 304-664-3922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLVN-164X00000X
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: