Provider Demographics
NPI:1467124651
Name:BROCK, MARCIUS R (LPC)
Entity Type:Individual
Prefix:MR
First Name:MARCIUS
Middle Name:R
Last Name:BROCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 ALPINE WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-7518
Mailing Address - Country:US
Mailing Address - Phone:507-317-5247
Mailing Address - Fax:
Practice Address - Street 1:1045 ALPINE WAY
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-7518
Practice Address - Country:US
Practice Address - Phone:507-317-5247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006936101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional