Provider Demographics
NPI:1710400916
Name:BROCKMAN, RANDY (CAADE 1711108)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:CAADE 1711108
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ELM ST STE 212
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-3070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 PRICE AVE
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1463
Practice Address - Country:US
Practice Address - Phone:650-591-9623
Practice Address - Fax:650-591-4163
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)