Provider Demographics
NPI:1992714703
Name:FERGUSON, KERRY BROCK (PHD)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:BROCK
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:LYNN
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34755-0809
Mailing Address - Country:US
Mailing Address - Phone:352-536-9737
Mailing Address - Fax:321-939-3652
Practice Address - Street 1:442 N DILLARD ST STE 1
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-2818
Practice Address - Country:US
Practice Address - Phone:352-536-9737
Practice Address - Fax:407-614-1900
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6092103T00000X, 103TE1100X, 103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service