Provider Demographics
NPI:1992103170
Name:BEASLEY, RANDOLPH
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12200 LINCOLNSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-9582
Mailing Address - Country:US
Mailing Address - Phone:530-522-8489
Mailing Address - Fax:
Practice Address - Street 1:12200 LINCOLNSHIRE DR
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-9582
Practice Address - Country:US
Practice Address - Phone:530-522-8489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-20
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
AK207210106H00000X
CA120092106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#95-2633765OtherMEDI-CAL