Basic Information
| Provider Information | |||||||||
| NPI: | 1710400916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCKMAN | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CAADE 1711108 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 ELM ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940703070 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 609 PRICE AVE | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940631463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505919623 | ||||||||
| FaxNumber: | 6505914163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2017 | ||||||||
| LastUpdateDate: | 07/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.