Provider Demographics
NPI:1396457784
Name:FERGUSON, TIONNA
Entity type:Individual
Prefix:
First Name:TIONNA
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 SCRIMSHAW DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2573
Mailing Address - Country:US
Mailing Address - Phone:804-484-0899
Mailing Address - Fax:
Practice Address - Street 1:4401 STIGALL DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3217
Practice Address - Country:US
Practice Address - Phone:804-484-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities