Provider Demographics
NPI:1245424779
Name:BURGESS, RANDALL
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:BURGESS
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 1:6801 COLDWATER CANYON AVE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-5162
Mailing Address - Country:US
Mailing Address - Phone:818-763-1718
Mailing Address - Fax:818-763-7231
Practice Address - Street 1:6801 COLDWATER CANYON AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-5162
Practice Address - Country:US
Practice Address - Phone:818-763-1718
Practice Address - Fax:818-763-7231
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF53814101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor