=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295015030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ECHO ROCK THERAPY CENTER, 501(C) 3
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2011
-----------------------------------------------------
Last Update Date | 08/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 CAMINO ALTO SUITE 200
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-2929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-302-4858
-----------------------------------------------------
Fax | 415-737-1389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 CAMINO ALTO SUITE 200
-----------------------------------------------------
City | MILL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94941-2929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-302-4858
-----------------------------------------------------
Fax | 415-737-1389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VICTORIA VOGEL
-----------------------------------------------------
Credential | MFT
-----------------------------------------------------
Telephone | 415-302-4858
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 29744
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------