Provider Demographics
NPI:1790037000
Name:ROCKAFELLOW PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:ROCKAFELLOW PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:ROCKAFELLOW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:248-656-0500
Mailing Address - Street 1:1000 W UNIVERSITY DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1873
Mailing Address - Country:US
Mailing Address - Phone:248-656-0500
Mailing Address - Fax:248-656-0501
Practice Address - Street 1:1000 W UNIVERSITY DR
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1873
Practice Address - Country:US
Practice Address - Phone:248-656-0500
Practice Address - Fax:248-656-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5203Medicare UPIN