Provider Demographics
NPI:1124271184
Name:WYATT, RANDALL CRAIG (PHD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:CRAIG
Last Name:WYATT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BEACH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-1221
Mailing Address - Country:US
Mailing Address - Phone:415-955-2076
Mailing Address - Fax:415-955-2179
Practice Address - Street 1:4283 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-4758
Practice Address - Country:US
Practice Address - Phone:510-610-1097
Practice Address - Fax:415-955-2179
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY1220103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical