Provider Demographics
NPI:1639182801
Name:FANTOZZI, DONNA (LPC)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:FANTOZZI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:FEDYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1217 WOODLAND POINT DRIVE
Mailing Address - Street 2:UNIT L
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-1837
Mailing Address - Country:US
Mailing Address - Phone:314-906-0054
Mailing Address - Fax:314-469-3523
Practice Address - Street 1:1217 WOODLAND POINT DR.
Practice Address - Street 2:UNIT L
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-1837
Practice Address - Country:US
Practice Address - Phone:314-906-0054
Practice Address - Fax:314-469-3523
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002713101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO182434OtherBLUE CROSS BLUE SHIELD