Provider Demographics
NPI:1154652725
Name:JOHNSON, RANDI SCALISE
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:SCALISE
Last Name:JOHNSON
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 1:3172 WALFORD AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-4897
Mailing Address - Country:US
Mailing Address - Phone:707-444-0267
Mailing Address - Fax:
Practice Address - Street 1:3172 WALFORD AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4897
Practice Address - Country:US
Practice Address - Phone:707-444-0267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23983106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist