Healthcare Provider Details

I. General information

NPI: 1356424972
Provider Name (Legal Business Name): FREDERICK A ULAM III PHD, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E CATALPA ST
SPRINGFIELD MO
65807-1614
US

IV. Provider business mailing address

516 E CATALPA ST
SPRINGFIELD MO
65807-1614
US

V. Phone/Fax

Practice location:
  • Phone: 417-864-8920
  • Fax:
Mailing address:
  • Phone: 417-864-8920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPYR0452
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPYR0452
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPYR0452
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPYR0452
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberR0452
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPYR0452
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: