Provider Demographics
NPI:1649997636
Name:FERGUSON, ROBERT (MATS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MATS
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 1064
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-1064
Mailing Address - Country:US
Mailing Address - Phone:907-347-8619
Mailing Address - Fax:
Practice Address - Street 1:1828 CRANDELL
Practice Address - Street 2:
Practice Address - City:HEBER
Practice Address - State:AZ
Practice Address - Zip Code:85928-5606
Practice Address - Country:US
Practice Address - Phone:907-347-8619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11866128253J00000X, 385HR2055X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child