Provider Demographics
NPI:1750704060
Name:FERGUSON, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-3968
Mailing Address - Country:US
Mailing Address - Phone:609-394-8988
Mailing Address - Fax:
Practice Address - Street 1:132 PERRY ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-3968
Practice Address - Country:US
Practice Address - Phone:609-394-8988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0102903OtherNJ MEDICAID PROVIDER
NJ215114000OtherMAGELLAN MIS
NJ7603606OtherWFNJ-SAI GROUP
NJ2000078OtherDHS LICENSE AMBULATORY
NJ2000345-MV1-10OtherDHS DMHAS MOBILE UNIT
NJ183739OtherYBA4
NJNJ-10046-MOtherSUBSTANCE ABUSE AND MENTAL HEALTH
NJ2000345OtherDHS LICENSE AMBULATORY CARE
NJ2000345-MV1-10OtherDHS DMHAS MOBILE UNIT