Provider Demographics
NPI:1851309876
Name:LAROCQUE, MARY A (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:LAROCQUE
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:KLINEDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:7311A W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6237
Mailing Address - Country:US
Mailing Address - Phone:260-471-8033
Mailing Address - Fax:260-471-8107
Practice Address - Street 1:7806 W JEFFERSON BLVD STE C
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4180
Practice Address - Country:US
Practice Address - Phone:260-203-4188
Practice Address - Fax:260-203-5136
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001252A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200800080Medicaid
176540DMedicare ID - Type Unspecified