Healthcare Provider Details

I. General information

NPI: 1275952012
Provider Name (Legal Business Name): MARY JO LAROSE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 FRANKLIN ST STE 200
MICHIGAN CITY IN
46360-3564
US

IV. Provider business mailing address

710 FRANKLIN ST STE 200
MICHIGAN CITY IN
46360-3564
US

V. Phone/Fax

Practice location:
  • Phone: 219-872-6200
  • Fax: 219-879-2915
Mailing address:
  • Phone: 219-872-6200
  • Fax: 219-879-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number34006321A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: