Healthcare Provider Details

I. General information

NPI: 1053425769
Provider Name (Legal Business Name): LORETTA FUGE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 03/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 W COMMERCIAL ST
MANSFIELD MO
65704-9520
US

IV. Provider business mailing address

827 W. COMMERCIAL P.O. BOX 47
MANSFIELD MO
65704-0677
US

V. Phone/Fax

Practice location:
  • Phone: 417-924-8188
  • Fax: 417-924-8190
Mailing address:
  • Phone: 417-924-8188
  • Fax: 417-924-8190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2005028862
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: