Healthcare Provider Details

I. General information

NPI: 1588608061
Provider Name (Legal Business Name): WILLIAM M BUMBERRY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 112A
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 112A
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6545
  • Fax: 314-251-5808
Mailing address:
  • Phone: 314-251-6545
  • Fax: 314-251-5808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberR0061
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: