Healthcare Provider Details

I. General information

NPI: 1477577922
Provider Name (Legal Business Name): SCUDDY F. FONTENELLE III PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 RIDGELAKE DR
METAIRIE LA
70001-5312
US

IV. Provider business mailing address

118 RIDGELAKE DR
METAIRIE LA
70001-5312
US

V. Phone/Fax

Practice location:
  • Phone: 504-834-2775
  • Fax: 504-834-2378
Mailing address:
  • Phone: 504-834-2775
  • Fax: 504-834-2378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number457
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSP301
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: