MEDICARE: MR. RICHARD M BALLARD JR. LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2008034053	MO

General Provider Information

NPI Number	:	1053554543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD M BALLARD JR. LCSW

Provider Business Mailing Address
First Line	:	2301 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2908
Country	:	US
Telephone Number	:	888-657-3201
Fax Number	:	314-721-3295

Provider Business Practice Location Address
First Line	:	2301 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2908
Country	:	US
Telephone Number	:	888-657-3201
Fax Number	:	314-781-3295

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2009
Last Update Date	:	04/13/2009

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