Provider Demographics
NPI:1316583735
Name:FERGUSON, KERRY A
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:A
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 1:1008 W OHIO ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47872-1536
Mailing Address - Country:US
Mailing Address - Phone:765-569-5350
Mailing Address - Fax:765-569-5340
Practice Address - Street 1:1008 W OHIO ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47872-1536
Practice Address - Country:US
Practice Address - Phone:765-569-5350
Practice Address - Fax:765-569-5340
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99096255A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN99096255AOtherLICENSE