Provider Demographics
NPI:1568719953
Name:GROOM, RALPH WILLIAM JR (LCSW, LBA)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:WILLIAM
Last Name:GROOM
Suffix:JR
Gender:M
Credentials:LCSW, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3877 HUMPHREY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4825
Mailing Address - Country:US
Mailing Address - Phone:314-704-0900
Mailing Address - Fax:
Practice Address - Street 1:3877 HUMPHREY ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4825
Practice Address - Country:US
Practice Address - Phone:314-704-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013028554103K00000X
MO20160041031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst