Provider Demographics
NPI:1699168872
Name:RANDALL, KRISTY (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 VISTA WAY
Mailing Address - Street 2:SUITE 258
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4565
Mailing Address - Country:US
Mailing Address - Phone:760-758-1480
Mailing Address - Fax:
Practice Address - Street 1:3605 VISTA WAY
Practice Address - Street 2:SUITE 258
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056
Practice Address - Country:US
Practice Address - Phone:760-758-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X
CA1041C0700X
CAASW64767390200000X
CALCSW834191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program