Provider Demographics
NPI:1346505021
Name:GROH, RYAN MATTHEW (LPC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:GROH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 MONROE ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-1358
Mailing Address - Country:US
Mailing Address - Phone:920-627-2793
Mailing Address - Fax:
Practice Address - Street 1:641 MONROE ST
Practice Address - Street 2:SUITE 111
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-1358
Practice Address - Country:US
Practice Address - Phone:920-627-2793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4834-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional