Provider Demographics
NPI:1346374824
Name:LEDOM, WESLEY MAX (PHD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:MAX
Last Name:LEDOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7524 EATON ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-3610
Mailing Address - Country:US
Mailing Address - Phone:913-634-5199
Mailing Address - Fax:
Practice Address - Street 1:7524 EATON ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-3610
Practice Address - Country:US
Practice Address - Phone:913-634-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000290103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493240121Medicaid
MO0004904Medicare ID - Type Unspecified
MOR62605Medicare UPIN