Provider Demographics
NPI:1275952012
Name:LAROSE, MARY JO (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:LAROSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 FRANKLIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3564
Mailing Address - Country:US
Mailing Address - Phone:219-872-6200
Mailing Address - Fax:219-879-2915
Practice Address - Street 1:710 FRANKLIN ST STE 200
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3564
Practice Address - Country:US
Practice Address - Phone:219-872-6200
Practice Address - Fax:219-879-2915
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006321A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34006321AOtherLICENSE