Provider Demographics
NPI:1679202030
Name:FERGUSON, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
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 1:56 WHITING ST UNIT 846
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-7734
Mailing Address - Country:US
Mailing Address - Phone:860-368-8665
Mailing Address - Fax:
Practice Address - Street 1:2 BRIAR CLF
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06013-2233
Practice Address - Country:US
Practice Address - Phone:860-368-8665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005318101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health