Provider Demographics
NPI:1649798281
Name:FERGUSON, LYDIA (BEHAVIOR ANALYST)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:BEHAVIOR ANALYST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563
Mailing Address - Country:US
Mailing Address - Phone:800-676-5130
Mailing Address - Fax:888-958-5753
Practice Address - Street 1:645 BALTIMORE ANNAPOLIS BLVD SUITE 216-217
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146
Practice Address - Country:US
Practice Address - Phone:800-676-5130
Practice Address - Fax:888-958-5753
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103K00000X
MDRBT-17-38277106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician