John Edd Bucklew, PH.D.
Individual provider Active NPI Psychologist · Fulton, MO
NPI 1962685446 · NPPES record last updated Dec 7, 2007
Key facts
- NPI
- 1962685446
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Psychologist 103T00000X
- License
- 00975 (MO)
- Practice address
- 600 E 5TH St
Fulton, MO 65251-1753 - Phone
- (573) 592-2796
- NPI assigned
- Dec 7, 2007
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 00975 | MO | MD | Speech-Language Pathologist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 00975 | MO | Yes |
Addresses
Primary practice location
600 E 5TH St
Fulton, MO 65251-1753
Mailing address
600 E 5TH St
Fulton, MO 65251-1753
Phone (573) 592-2796
Other providers in Fulton, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 7, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.