MEDICARE: RACHELLE FERGUSON BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-14-16967	TX

General Provider Information

NPI Number	:	1114317807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHELLE FERGUSON BCBA

Provider Business Mailing Address
First Line	:	555 E 5TH ST APT 3022
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78701-4153
Country	:	US
Telephone Number	:	512-255-1720
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 E 5TH ST APT 3022
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78701-4153
Country	:	US
Telephone Number	:	512-255-1720
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2015
Last Update Date	:	02/02/2015

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