Provider Demographics
NPI:1457688327
Name:STOTLAND, RANDY E (PHD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:E
Last Name:STOTLAND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3368 GOVERNOR DR # F249
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-2936
Mailing Address - Country:US
Mailing Address - Phone:858-558-7342
Mailing Address - Fax:858-492-7290
Practice Address - Street 1:4382 ROUS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2631
Practice Address - Country:US
Practice Address - Phone:858-558-7342
Practice Address - Fax:858-492-7290
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5946103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACZ686AMedicare PIN