Provider Demographics
NPI:1336751296
Name:FERGUSON, CALLIE (T-LMLP)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:T-LMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 S CLIFF AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6969
Mailing Address - Country:US
Mailing Address - Phone:816-608-1956
Mailing Address - Fax:800-687-5070
Practice Address - Street 1:333 OZARK TRAIL DR STE 50
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2185
Practice Address - Country:US
Practice Address - Phone:636-398-2500
Practice Address - Fax:800-687-5070
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2996103TC0700X
RBT-23-285207106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical