Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | PYR0452 | MO |
N | 103TC0700X | Clinical Psychologist | PYR0452 | MO |
N | 103TA0700X | Adult Development & Aging Psychologist | PYR0452 | MO |
N | 103TB0200X | Cognitive & Behavioral Psychologist | PYR0452 | MO |
Y | 103G00000X | Clinical Psychologist | PYR0452 | MO |
Y | 103TC0700X | Clinical Psychologist | PYR0452 | MO |
N | 103G00000X | Clinical Psychologist | R0452 | MO |
N | 103TC0700X | Clinical Psychologist | R0452 | MO |
N | 103TR0400X | Rehabilitation Psychologist | PYR0452 | MO |
NPI | 1356424972 |
---|---|
Provider Name | Frederick A Ulam III |
First Address | Springfield, MO 65807-1614 |
Second Address | Springfield, MO 65807-1614 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2006 |
Last Update Date | 29/04/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
495011611 | (05) | MO |
P00174113 | RAILROAD MEDICARE (01) | MO |