Provider Demographics
NPI:1043717291
Name:RANDHAWA, UPKAR
Entity Type:Individual
Prefix:
First Name:UPKAR
Middle Name:
Last Name:RANDHAWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15980 OLD GLORY WAY
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-9395
Mailing Address - Country:US
Mailing Address - Phone:925-724-6940
Mailing Address - Fax:
Practice Address - Street 1:2291 W MARCH LN STE C101
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6669
Practice Address - Country:US
Practice Address - Phone:916-745-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician