Provider Demographics
NPI:1750955316
Name:MARSHALL, ALEXANDER GRUBER (LPC-IT, SAC-IT)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:GRUBER
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-1518
Mailing Address - Country:US
Mailing Address - Phone:252-334-4340
Mailing Address - Fax:262-334-4341
Practice Address - Street 1:400 W RIVER DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-1518
Practice Address - Country:US
Practice Address - Phone:252-334-4340
Practice Address - Fax:262-334-4341
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19460-130101YA0400X
WI5095-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)