=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346374824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WESLEY MAX LEDOM PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 09/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7524 EATON ST
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66208-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-634-5199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7524 EATON ST
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66208-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-634-5199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 000290
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------