Provider Demographics
NPI:1114438181
Name:BROCK, ALEXANDER PATRICK (MS)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:PATRICK
Last Name:BROCK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4345
Mailing Address - Country:US
Mailing Address - Phone:503-951-6280
Mailing Address - Fax:503-468-3130
Practice Address - Street 1:1515 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4345
Practice Address - Country:US
Practice Address - Phone:503-951-6280
Practice Address - Fax:503-468-3130
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORC5601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor