Provider Demographics
NPI:1124054119
Name:DAVIS, RANDALL B (LMFT)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3943 IRVINE BLVD # 406
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2400
Mailing Address - Country:US
Mailing Address - Phone:951-736-8193
Mailing Address - Fax:888-388-0170
Practice Address - Street 1:1101 CALIFORNIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-6472
Practice Address - Country:US
Practice Address - Phone:951-736-8193
Practice Address - Fax:888-388-0170
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19383106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19383OtherMFC