Provider Demographics
NPI:1558342378
Name:ROCKAFELLOW, BRADLEY D (PHD)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:D
Last Name:ROCKAFELLOW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 SOUTH BLVD E
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5465
Mailing Address - Country:US
Mailing Address - Phone:248-212-3153
Mailing Address - Fax:248-656-0500
Practice Address - Street 1:1055 SOUTH BLVD E
Practice Address - Street 2:SUITE 210
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5465
Practice Address - Country:US
Practice Address - Phone:248-212-3153
Practice Address - Fax:248-656-0500
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014045103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical