Provider Demographics
NPI:1538138375
Name:FOURNELLE, ROGER J JR (MED LPC NCC NCP)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:J
Last Name:FOURNELLE
Suffix:JR
Gender:M
Credentials:MED LPC NCC NCP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3831 BOWEN ST
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3123
Mailing Address - Country:US
Mailing Address - Phone:314-752-9445
Mailing Address - Fax:314-752-9445
Practice Address - Street 1:3720 HAMPTON AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1438
Practice Address - Country:US
Practice Address - Phone:314-559-4209
Practice Address - Fax:314-752-9445
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
61290101Y00000X
MO2000152363101YP2500X
01194103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO179068OtherBLUE CROSS BLUE SHIELD
7811255OtherAETNA