Provider Demographics
NPI:1356424972
Name:ULAM, FREDERICK A III (PHD, LP)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:A
Last Name:ULAM
Suffix:III
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E CATALPA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1614
Mailing Address - Country:US
Mailing Address - Phone:417-864-8920
Mailing Address - Fax:
Practice Address - Street 1:516 E CATALPA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1614
Practice Address - Country:US
Practice Address - Phone:417-864-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPYR0452103G00000X, 103TA0700X, 103TB0200X, 103TR0400X, 103TC0700X
MOR0452103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495011611Medicaid
MOP00174113OtherRAILROAD MEDICARE
MO216331383Medicare ID - Type Unspecified