Healthcare Provider Details

I. General information

NPI: 1407209620
Provider Name (Legal Business Name): MARVEL LAROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 CHESTNUT ST
RANDOLPH MA
02368-2407
US

IV. Provider business mailing address

101 S MAIN ST
RANDOLPH MA
02368-4896
US

V. Phone/Fax

Practice location:
  • Phone: 857-991-0110
  • Fax:
Mailing address:
  • Phone: 857-991-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2292446
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: