Provider Demographics
NPI:1669824025
Name:RAYMOND T FEZZI, LCSW
Entity Type:Organization
Organization Name:RAYMOND T FEZZI, LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:T
Authorized Official - Last Name:FEZZI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-894-9696
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0007751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO753263201Medicaid
MO753263201Medicaid