Provider Demographics
NPI:1568722874
Name:FERGUSON, KELLY WAYNE (MA, LMFT)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:WAYNE
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 DOGWOOD CV
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-7627
Mailing Address - Country:US
Mailing Address - Phone:386-214-4351
Mailing Address - Fax:662-844-1757
Practice Address - Street 1:1916 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4114
Practice Address - Country:US
Practice Address - Phone:662-281-1306
Practice Address - Fax:662-281-1326
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0897101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)