Provider Demographics
NPI:1528236908
Name:LAROQUE, SEAN DAVIS (PHD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:DAVIS
Last Name:LAROQUE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2715
Mailing Address - Country:US
Mailing Address - Phone:414-870-1111
Mailing Address - Fax:
Practice Address - Street 1:155 E CAPITOL DR
Practice Address - Street 2:5C
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-2134
Practice Address - Country:US
Practice Address - Phone:414-870-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86858103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool