Provider Demographics
NPI:1205210622
Name:ECHO ROCK NEUROTHERAPY
Entity Type:Organization
Organization Name:ECHO ROCK NEUROTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL CO-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:415-302-4848
Mailing Address - Street 1:45 CAMINO ALTO
Mailing Address - Street 2:STE 204
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2929
Mailing Address - Country:US
Mailing Address - Phone:415-302-4848
Mailing Address - Fax:
Practice Address - Street 1:45 CAMINO ALTO
Practice Address - Street 2:STE 204
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2929
Practice Address - Country:US
Practice Address - Phone:415-302-4848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 28068251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management