Provider Demographics
NPI:1578711206
Name:HERMAN, RANDY MARK (MFT)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:MARK
Last Name:HERMAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 HIGH BLUFF DR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2052
Mailing Address - Country:US
Mailing Address - Phone:858-356-9786
Mailing Address - Fax:858-356-9786
Practice Address - Street 1:12625 HIGH BLUFF DR
Practice Address - Street 2:SUITE 114
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2052
Practice Address - Country:US
Practice Address - Phone:858-356-9786
Practice Address - Fax:858-356-9786
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-06
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43284106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11811135OtherCAQH PROVIDER ID