Provider Demographics
NPI:1376567552
Name:LAQUERRE, MARC CONRAD (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:CONRAD
Last Name:LAQUERRE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-2707
Mailing Address - Country:US
Mailing Address - Phone:603-345-3786
Mailing Address - Fax:
Practice Address - Street 1:120 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-2707
Practice Address - Country:US
Practice Address - Phone:603-345-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH756103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30420513Medicaid
NH30420513Medicaid