Provider Demographics
NPI:1497576110
Name:FERGUSON, KIM (LAC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7302 W JOHN GARRISON RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-9475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 SOUTHWINDS RD STE 5
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-8685
Practice Address - Country:US
Practice Address - Phone:479-466-0716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2001016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health