Provider Demographics
NPI:1063502920
Name:FEZZI, RAYMOND THOMAS (MSW)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:THOMAS
Last Name:FEZZI
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6220 S LINDBERGH BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-7839
Mailing Address - Country:US
Mailing Address - Phone:314-894-9696
Mailing Address - Fax:314-894-2942
Practice Address - Street 1:6220 S LINDBERGH BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7839
Practice Address - Country:US
Practice Address - Phone:314-894-9696
Practice Address - Fax:314-894-2942
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0007751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO753263201Medicaid
MOR01082Medicare UPIN