Healthcare Provider Details

I. General information

NPI: 1013420181
Provider Name (Legal Business Name): NJLAROCQUE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 MASSACHUSETTS AVE STE 101F
ACTON MA
01720-2963
US

IV. Provider business mailing address

525 MASSACHUSETTS AVE STE 101F
ACTON MA
01720-2963
US

V. Phone/Fax

Practice location:
  • Phone: 617-331-1180
  • Fax: 888-430-8150
Mailing address:
  • Phone: 617-331-1180
  • Fax: 888-430-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number114971
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number114971
License Number StateMA

VIII. Authorized Official

Name: NICOLE JEAN LAROCQUE
Title or Position: OWNER/MANAGER
Credential: LICSW
Phone: 617-331-1180