Provider Demographics
NPI:1477552842
Name:FORTEL, DAVID W (LPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:FORTEL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N GARTH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4103
Mailing Address - Country:US
Mailing Address - Phone:573-443-2204
Mailing Address - Fax:573-875-5851
Practice Address - Street 1:600 W MORRISON ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1075
Practice Address - Country:US
Practice Address - Phone:660-248-3313
Practice Address - Fax:600-248-3313
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001328101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO326443OtherHEALTHLINK
MO22241OtherBCBS
MO22241OtherANTHEM EAP