Provider Demographics
NPI:1679575104
Name:FERGUSON, KATHLEEN S (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:S
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 CARVER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5527
Mailing Address - Country:US
Mailing Address - Phone:513-984-9940
Mailing Address - Fax:513-984-9858
Practice Address - Street 1:4450 CARVER WOODS DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-5527
Practice Address - Country:US
Practice Address - Phone:513-984-9940
Practice Address - Fax:513-984-9858
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5943103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11645952OtherCAQH
OH2570927Medicaid
OH2570927Medicaid