1053425769 NPI number — DR. LORETTA FUGE PSY.D.

Table of content: DR. LORETTA FUGE PSY.D. (NPI 1053425769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053425769 NPI number — DR. LORETTA FUGE PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUGE
Provider First Name:
LORETTA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053425769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
827 W. COMMERCIAL
Provider Second Line Business Mailing Address:
P.O. BOX 47
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65704-0677
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-924-8188
Provider Business Mailing Address Fax Number:
417-924-8190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 W COMMERCIAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65704-9520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-924-8188
Provider Business Practice Location Address Fax Number:
417-924-8190
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  2005028862 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1285906107 . This is a "CORNERSTONE PSYCHOLOGICAL SERVICES" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 498979111 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 218034 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1366779100 . This is a "GROUP PRACTICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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