Provider Demographics
NPI:1538178207
Name:FERGUSON, LARA CYNDEYRN (PHD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:CYNDEYRN
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2450 PERALTA BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-3823
Mailing Address - Country:US
Mailing Address - Phone:510-791-8373
Mailing Address - Fax:650-363-1513
Practice Address - Street 1:2450 PERALTA BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3823
Practice Address - Country:US
Practice Address - Phone:510-791-8373
Practice Address - Fax:650-363-1513
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6244103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
00PL62440Medicare ID - Type Unspecified