Provider Demographics
NPI:1124737028
Name:ECKERT, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:ECKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4670 WOODFIELD CT APT 5
Mailing Address - Street 2:
Mailing Address - City:NASHOTAH
Mailing Address - State:WI
Mailing Address - Zip Code:53058-9647
Mailing Address - Country:US
Mailing Address - Phone:608-290-8089
Mailing Address - Fax:
Practice Address - Street 1:2314 N GRANDVIEW BLVD STE 207
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1675
Practice Address - Country:US
Practice Address - Phone:262-408-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10151-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional