Provider Demographics
NPI:1194569293
Name:FARASE, RANDOLPH
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:FARASE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9412 BIG HORN BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-1101
Mailing Address - Country:US
Mailing Address - Phone:916-609-5100
Mailing Address - Fax:
Practice Address - Street 1:9412 BIG HORN BLVD STE 6
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-1101
Practice Address - Country:US
Practice Address - Phone:916-609-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT143296106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist