Healthcare Provider Details

I. General information

NPI: 1336968932
Provider Name (Legal Business Name): MRS. AUDREY ROSE FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33955 EMILIA LN
FREMONT CA
94555-2068
US

IV. Provider business mailing address

33955 EMILIA LN
FREMONT CA
94555-2068
US

V. Phone/Fax

Practice location:
  • Phone: 510-794-0392
  • Fax:
Mailing address:
  • Phone: 510-794-0392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number210056935
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: