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General NPI Number Information
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NPI Number | 1366779100
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Entity Type | Organization
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Legal Business Name | GREATER OZARKS RURAL PSYCHOLOGISTS LLC
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Dates
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Enumeration Date | 11/16/2009
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Last Update Date | 12/14/2009
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Provider Practice Location Address
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Address Line | 827 W COMMERCIAL ST
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City | MANSFIELD
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State | MO
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Zip | 65704-9520
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Country | US
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Telephone | 417-924-8188
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Fax | 417-924-8188
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Provider Business Mailing Address
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Address Line | 827 W COMMERCIAL ST P.O. BOX 47
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City | MANSFIELD
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State | MO
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Zip | 65704-9520
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Country | US
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Telephone | 417-924-8188
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Fax | 417-924-8188
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. LORETTA S. FUGE
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Credential | PSY.D.
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Telephone | 417-924-8188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2005028862
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License Number State | MO
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