Provider Demographics
NPI:1275757411
Name:FERGUSON, TERESA LYNN (EDS)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 526
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:WV
Mailing Address - Zip Code:25621-0526
Mailing Address - Country:US
Mailing Address - Phone:304-664-3922
Mailing Address - Fax:
Practice Address - Street 1:1609 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3006
Practice Address - Country:US
Practice Address - Phone:304-235-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVLVN-164X00000X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)