Provider Demographics
NPI:1366566697
Name:AVSHALOMOV, RANDI L (MA, MFT)
Entity type:Individual
Prefix:MS
First Name:RANDI
Middle Name:L
Last Name:AVSHALOMOV
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:MS
Other - First Name:RANDI
Other - Middle Name:L
Other - Last Name:GRAFMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, MFT
Mailing Address - Street 1:4026 PECK RD
Mailing Address - Street 2:#204
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-2247
Mailing Address - Country:US
Mailing Address - Phone:626-444-0539
Mailing Address - Fax:626-444-7990
Practice Address - Street 1:4026 PECK RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-2247
Practice Address - Country:US
Practice Address - Phone:626-444-0539
Practice Address - Fax:626-444-7990
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC13289106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRA0721OtherSTAFF CODE