Basic Information
| Provider Information | |||||||||
| NPI: | 1518327618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDALL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | AMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 N. JONSON AVE. | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194420277 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 N. JONSON AVE. | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194420277 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/21/2019 | ||||||||
| NPIReactivationDate: | 12/27/2019 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.