Healthcare Provider Details

I. General information

NPI: 1083666143
Provider Name (Legal Business Name): LARRY DALE SQUIRES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MEDIC WAY
GREENCASTLE IN
46135-2296
US

IV. Provider business mailing address

9501 W WOLF MOUNTAIN RD
GOSPORT IN
47433-9597
US

V. Phone/Fax

Practice location:
  • Phone: 765-653-2669
  • Fax: 765-653-8671
Mailing address:
  • Phone: 812-876-4151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34001063A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: