Provider Demographics
NPI:1356858088
Name:FERGUSON, KIMBERLY (MA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7109 DANNY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-5320
Mailing Address - Country:US
Mailing Address - Phone:209-957-7777
Mailing Address - Fax:209-473-3344
Practice Address - Street 1:7109 DANNY DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-5320
Practice Address - Country:US
Practice Address - Phone:209-957-7777
Practice Address - Fax:209-473-3344
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17-43153106S00000X
CA1-21-47617103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician