Provider Demographics
NPI:1053425769
Name:FUGE, LORETTA (PSYD)
Entity type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:
Last Name:FUGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 W. COMMERCIAL
Mailing Address - Street 2:P.O. BOX 47
Mailing Address - City:MANSFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65704-0677
Mailing Address - Country:US
Mailing Address - Phone:417-924-8188
Mailing Address - Fax:417-924-8190
Practice Address - Street 1:827 W COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MO
Practice Address - Zip Code:65704-9520
Practice Address - Country:US
Practice Address - Phone:417-924-8188
Practice Address - Fax:417-924-8190
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2012-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005028862103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1285906107OtherCORNERSTONE PSYCHOLOGICAL SERVICES
MO498979111Medicaid
MO218034OtherBLUE CROSS BLUE SHIELD
MO1366779100OtherGROUP PRACTICE
MO1366779100OtherGROUP PRACTICE
MO220794987Medicare PIN