Provider Demographics
NPI:1598202632
Name:LAROSE, LANAE IVY
Entity Type:Individual
Prefix:
First Name:LANAE
Middle Name:IVY
Last Name:LAROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 LIBERTY ST
Mailing Address - Street 2:APT B
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3306
Mailing Address - Country:US
Mailing Address - Phone:781-941-0759
Mailing Address - Fax:
Practice Address - Street 1:67 LIBERTY ST
Practice Address - Street 2:APT B
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3306
Practice Address - Country:US
Practice Address - Phone:781-941-0759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst