Healthcare Provider Details

I. General information

NPI: 1316528847
Provider Name (Legal Business Name): MATTHEW FUQUA MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 N JEFFERSON AVE FL 3
SPRINGFIELD MO
65802-1917
US

IV. Provider business mailing address

2885 W BATTLEFIELD ST
SPRINGFIELD MO
65807-3952
US

V. Phone/Fax

Practice location:
  • Phone: 417-761-5000
  • Fax:
Mailing address:
  • Phone: 417-761-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2019027209
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPENDING
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11212-M
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022042255
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: