Provider Demographics
NPI:1336463397
Name:CHAMBERS, RANDOLPH
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:
Last Name:CHAMBERS
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 1:1796 BAY RD
Mailing Address - Street 2:
Mailing Address - City:EAST PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-1611
Mailing Address - Country:US
Mailing Address - Phone:650-462-6999
Mailing Address - Fax:650-462-1055
Practice Address - Street 1:1796 BAY RD
Practice Address - Street 2:
Practice Address - City:EAST PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-1611
Practice Address - Country:US
Practice Address - Phone:650-462-6999
Practice Address - Fax:650-462-1055
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA410027AN101YA0400X
CA4100274LN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWILLIAMSHOUSE I &IIMedicaid
CAWALKERHOUSE2Medicaid