Provider Demographics
NPI:1538444930
Name:ROCKAFELLOW PSYCHOLOGICAL SERVICES PC
Entity type:Organization
Organization Name:ROCKAFELLOW PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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
Authorized Official - Phone:248-212-3153
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:2011-10-17
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012927103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty