Individual
MR. GLENN JAMES LAROCK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LICSW
Contact information
Practice address
100 E IDAHO ST, BOISE, ID 83712-6267
(208) 381-2711
(208) 381-4025
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
089 0092617
VT
1041C0700X
Clinical Social Worker
110763
MA
1041C0700X
Clinical Social Worker
Primary
LCSW-35629
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1063650
NHP PROVIDER NUMBER
MA
01
—
416714
MAGELLAN PROVIDER NUMBER
MA
01
—
P08083
BCBS PROVIDER NUMBER
MA
Enumeration date
09/27/2006
Last updated
10/04/2023
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