Provider Demographics
NPI:1699136903
Name:GLYNN, RANDAL (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:RANDAL
Middle Name:
Last Name:GLYNN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 PERKINS ST APT 210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-3420
Mailing Address - Country:US
Mailing Address - Phone:908-892-3086
Mailing Address - Fax:
Practice Address - Street 1:9801 DUBLIN BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2835
Practice Address - Country:US
Practice Address - Phone:877-543-7852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23226235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist