Provider Demographics
NPI:1902400716
Name:ULLOM, STEVEN A
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:A
Last Name:ULLOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PEMBROKE CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-6404
Mailing Address - Country:US
Mailing Address - Phone:724-396-1510
Mailing Address - Fax:724-972-4627
Practice Address - Street 1:39 CHERRY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408-1015
Practice Address - Country:US
Practice Address - Phone:724-396-1510
Practice Address - Fax:724-972-4627
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1200509104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0425739Medicaid