Provider Demographics
NPI:1780379198
Name:FERGUSON, TYRA LAKIA (MA)
Entity type:Individual
Prefix:MS
First Name:TYRA
Middle Name:LAKIA
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1454 SUNSHADOW DR APT 100
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-9001
Mailing Address - Country:US
Mailing Address - Phone:786-306-0177
Mailing Address - Fax:
Practice Address - Street 1:651 W WARREN AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4036
Practice Address - Country:US
Practice Address - Phone:786-306-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)