Healthcare Provider Details

I. General information

NPI: 1922452044
Provider Name (Legal Business Name): THOMAS RUZICKA MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 FLORISSANT RD
SAINT LOUIS MO
63121-4835
US

IV. Provider business mailing address

7401 FLORISSANT RD
SAINT LOUIS MO
63121-4835
US

V. Phone/Fax

Practice location:
  • Phone: 314-261-6011
  • Fax: 314-385-1467
Mailing address:
  • Phone: 314-261-6011
  • Fax: 314-385-1467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2007033339
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: