Provider Demographics
NPI:1346508439
Name:FERGUSON, KRISTIN LEA (LAC)
Entity type:Individual
Prefix:MISS
First Name:KRISTIN
Middle Name:LEA
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7701 ZERO ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-6644
Mailing Address - Country:US
Mailing Address - Phone:479-478-5478
Mailing Address - Fax:479-478-5670
Practice Address - Street 1:7701 ZERO ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6644
Practice Address - Country:US
Practice Address - Phone:479-478-5478
Practice Address - Fax:479-478-5670
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1204035101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health