Provider Demographics
NPI:1952981334
Name:FERGERSON, TRISTA (AUTISM SPECIALIST)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:FERGERSON
Suffix:
Gender:F
Credentials:AUTISM SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 ANNETTE ST
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2811
Mailing Address - Country:US
Mailing Address - Phone:513-490-3643
Mailing Address - Fax:
Practice Address - Street 1:2603 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-6210
Practice Address - Country:US
Practice Address - Phone:513-490-3643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-10
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS00000103K00000X
KS106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty