Provider Demographics
NPI:1922791474
Name:BLACKSTONE, ALEXANDRIA MADISON MONTGOMERY (LPC-IT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:MADISON MONTGOMERY
Last Name:BLACKSTONE
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 S COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-6152
Mailing Address - Country:US
Mailing Address - Phone:920-722-8150
Mailing Address - Fax:
Practice Address - Street 1:400 N RICHMOND ST STE F1
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-4654
Practice Address - Country:US
Practice Address - Phone:920-722-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7397-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health