Healthcare Provider Details

I. General information

NPI: 1346168713
Provider Name (Legal Business Name): TIMOTHY A FUGATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 WINDSOR PL
MOBERLY MO
65270-1637
US

IV. Provider business mailing address

19 WINDSOR PL
MOBERLY MO
65270-1637
US

V. Phone/Fax

Practice location:
  • Phone: 573-397-1708
  • Fax:
Mailing address:
  • Phone: 573-397-1708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: