Provider Demographics
NPI:1508986456
Name:ECHO ROCK THERAPY CENTER
Entity Type:Organization
Organization Name:ECHO ROCK THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRCETOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:415-389-9430
Mailing Address - Street 1:30 CATALPA AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2802
Mailing Address - Country:US
Mailing Address - Phone:415-383-6048
Mailing Address - Fax:415-388-0111
Practice Address - Street 1:45 CAMINO ALTO
Practice Address - Street 2:STE 200
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2929
Practice Address - Country:US
Practice Address - Phone:415-383-6048
Practice Address - Fax:415-388-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-01
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28068101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty