Provider Demographics
NPI:1437234002
Name:BOFETTA, CATHY A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CATHY
Middle Name:A
Last Name:BOFETTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2202
Mailing Address - Country:US
Mailing Address - Phone:417-667-4230
Mailing Address - Fax:417-667-7607
Practice Address - Street 1:300 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-2202
Practice Address - Country:US
Practice Address - Phone:417-667-4230
Practice Address - Fax:417-667-7607
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004013225103TC0700X
KS1243103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000D165Medicare PIN