Provider Demographics
NPI:1215421441
Name:LARUE, MACKREA G (LISW-S)
Entity type:Individual
Prefix:
First Name:MACKREA
Middle Name:G
Last Name:LARUE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:MACKREA
Other - Middle Name:G
Other - Last Name:KILPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6779 ORCHARD TRAIL RD NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-2526
Mailing Address - Country:US
Mailing Address - Phone:234-401-0012
Mailing Address - Fax:
Practice Address - Street 1:6779 ORCHARD TRAIL RD NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-2526
Practice Address - Country:US
Practice Address - Phone:234-401-0012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.21027671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical