Provider Demographics
NPI:1023035656
Name:FUCETOLA, ROBERT P (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:P
Last Name:FUCETOLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-1408
Mailing Address - Fax:314-454-7759
Practice Address - Street 1:4444 FOREST PARK AVE
Practice Address - Street 2:DIV NEUROPSYCHOLOGY, 2ND FL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-362-1408
Practice Address - Fax:314-454-7759
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO01900103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490089004Medicaid
MO000070995Medicare PIN
MO680010437Medicare PIN