Provider Demographics
NPI:1083666143
Name:SQUIRES, LARRY DALE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:DALE
Last Name:SQUIRES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9501 W WOLF MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GOSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47433-9597
Mailing Address - Country:US
Mailing Address - Phone:812-876-4151
Mailing Address - Fax:
Practice Address - Street 1:308 MEDIC WAY
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2296
Practice Address - Country:US
Practice Address - Phone:765-653-2669
Practice Address - Fax:765-653-8671
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001063A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical