Provider Demographics
NPI:1558952234
Name:LAROCHE, ELIZABETH G (BEHAVIOR)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:G
Last Name:LAROCHE
Suffix:
Gender:F
Credentials:BEHAVIOR
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:DANIELLE
Other - Last Name:LAROCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 ANDERSON WAY
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-1601
Mailing Address - Country:US
Mailing Address - Phone:912-617-8889
Mailing Address - Fax:
Practice Address - Street 1:106 ANDERSON WAY
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-1601
Practice Address - Country:US
Practice Address - Phone:912-617-8889
Practice Address - Fax:912-342-4977
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-151335106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician