Provider Demographics
NPI:1003139890
Name:ENCISO, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:ENCISO
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 1:965 W SIERRA MADRE AVE
Mailing Address - Street 2:APT. #2
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-1836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5554 RESEDA BLVD STE 203
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-6212
Practice Address - Country:US
Practice Address - Phone:818-705-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA1-18-32353103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner