Healthcare Provider Details

I. General information

NPI: 1275966400
Provider Name (Legal Business Name): RONALD DELOS BAUDER JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5549 HIGHWAY K OLD HIGHWAY 13 GOOD SAMARITAN BOYS RANCH
BRIGHTON MO
65617
US

IV. Provider business mailing address

PO BOX 617 GOOD SAMARITAN BOYS RANCH
BRIGHTON MO
65617
US

V. Phone/Fax

Practice location:
  • Phone: 417-376-2238
  • Fax: 417-376-2014
Mailing address:
  • Phone: 417-376-2238
  • Fax: 417-376-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2012000124
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2014015230
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: