Provider Demographics
NPI:1194816884
Name:LAROCK, GLENN JAMES (LICSW)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:JAMES
Last Name:LAROCK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-381-2711
Practice Address - Fax:208-381-4025
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1107631041C0700X
VT089 00926171041C0700X
IDLCSW-356291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1063650OtherNHP PROVIDER NUMBER
MA416714OtherMAGELLAN PROVIDER NUMBER
MAP08083OtherBCBS PROVIDER NUMBER
MA1063650OtherNHP PROVIDER NUMBER