Provider Demographics
NPI:1336242379
Name:RUCK, MICHAEL A (ACSW, LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:RUCK
Suffix:
Gender:M
Credentials:ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 GOETHE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-3251
Mailing Address - Country:US
Mailing Address - Phone:314-352-7802
Mailing Address - Fax:314-352-7802
Practice Address - Street 1:4500 WEST PINE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2186
Practice Address - Country:US
Practice Address - Phone:314-352-7802
Practice Address - Fax:314-352-7802
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0002551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO78089Medicare UPIN