Healthcare Provider Details

I. General information

NPI: 1356858088
Provider Name (Legal Business Name): KIMBERLY FERGUSON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7109 DANNY DR
STOCKTON CA
95210-5320
US

IV. Provider business mailing address

7109 DANNY DR
STOCKTON CA
95210-5320
US

V. Phone/Fax

Practice location:
  • Phone: 209-957-7777
  • Fax: 209-473-3344
Mailing address:
  • Phone: 209-957-7777
  • Fax: 209-473-3344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-47617
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-43153
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: