MEDICARE: XAVIERA FERGUSON

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00000000	OTHER		NONE

General Provider Information

NPI Number	:	1790433407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	XAVIERA FERGUSON

Provider Business Mailing Address
First Line	:	800 N CENTRAL AVE APT 1225
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2777
Country	:	US
Telephone Number	:	775-351-4926
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 N CENTRAL AVE APT 1225
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2777
Country	:	US
Telephone Number	:	775-351-4926
Fax Number	:

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

Provider Enumeration Date	:	03/11/2022
Last Update Date	:	03/11/2022

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Directions to “ XAVIERA FERGUSON ” Practice Location

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