Provider Demographics
NPI:1154548840
Name:BALL, RANDAL GAIL (EDD)
Entity type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:GAIL
Last Name:BALL
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11573 LOS OSOS VALLEY ROAD
Mailing Address - Street 2:SUITE I
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405
Mailing Address - Country:US
Mailing Address - Phone:805-543-0431
Mailing Address - Fax:805-543-0481
Practice Address - Street 1:11573 LOS OSOS VALLEY ROAD
Practice Address - Street 2:SUITE I
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405
Practice Address - Country:US
Practice Address - Phone:805-543-0431
Practice Address - Fax:805-543-0481
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22042106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist