Provider Demographics
NPI:1942021589
Name:FULL DISCLOSURE THERAPY
Entity type:Organization
Organization Name:FULL DISCLOSURE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:310-570-6897
Mailing Address - Street 1:238 S NESKOWIN WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4964
Mailing Address - Country:US
Mailing Address - Phone:310-570-6897
Mailing Address - Fax:
Practice Address - Street 1:172 S ACADEMY AVE STE 150
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6564
Practice Address - Country:US
Practice Address - Phone:208-668-2701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty