Provider Demographics
NPI:1346799228
Name:WALBURGER, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:WALBURGER
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 1:1930 STEWART ST
Mailing Address - Street 2:X12
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4944
Mailing Address - Country:US
Mailing Address - Phone:310-828-9328
Mailing Address - Fax:310-828-9328
Practice Address - Street 1:1930 STEWART ST.
Practice Address - Street 2:X12
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4966
Practice Address - Country:US
Practice Address - Phone:310-828-9328
Practice Address - Fax:310-828-9328
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health