Healthcare Provider Details

I. General information

NPI: 1366779100
Provider Name (Legal Business Name): GREATER OZARKS RURAL PSYCHOLOGISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 12/14/2009
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 ST P.O. BOX 47
MANSFIELD MO
65704-9520
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. LORETTA S. FUGE
Title or Position: PSYCHOLOGIST
Credential: PSY.D.
Phone: 417-924-8188