Provider Demographics
NPI:1326681792
Name:FERGUSON, KASIA BOSEK
Entity Type:Individual
Prefix:
First Name:KASIA
Middle Name:BOSEK
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 1:4646 POPLAR AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4433
Mailing Address - Country:US
Mailing Address - Phone:901-930-7397
Mailing Address - Fax:
Practice Address - Street 1:560 COLONIAL RD STE 201
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4097
Practice Address - Country:US
Practice Address - Phone:901-930-7397
Practice Address - Fax:901-244-6528
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001617101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty