Basic Information
Provider Information
NPI: 1003139890
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ENCISO
FirstName: RANDY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
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OtherOrganizationType:  
OtherLastName:  
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Mailing Information
Address1: 965 W SIERRA MADRE AVE
Address2: APT. #2
City: AZUSA
State: CA
PostalCode: 917021836
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 5554 RESEDA BLVD STE 203
Address2:  
City: TARZANA
State: CA
PostalCode: 913566212
CountryCode: US
TelephoneNumber: 8187055522
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/08/2010
LastUpdateDate: 02/19/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
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IsSoleProprietor: Y
IsOrganizationSubpart:  
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AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225400000X  N Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner 
103K00000X1-18-32353CAY Behavioral Health & Social Service ProvidersBehavioral Analyst 

No ID Information.


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