Healthcare Provider Details

I. General information

NPI: 1851309876
Provider Name (Legal Business Name): MARY A LAROCQUE MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY A KLINEDORF MSW LCSW

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7806 W JEFFERSON BLVD STE C
FORT WAYNE IN
46804-4180
US

IV. Provider business mailing address

7311A W JEFFERSON BLVD
FORT WAYNE IN
46804-6237
US

V. Phone/Fax

Practice location:
  • Phone: 260-203-4188
  • Fax: 260-203-5136
Mailing address:
  • Phone: 260-471-8033
  • Fax: 260-471-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34001252A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: