Provider Demographics
NPI:1750642195
Name:SUTTLES, RANDY G
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:G
Last Name:SUTTLES
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 1:720 SS ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4245
Mailing Address - Country:US
Mailing Address - Phone:650-579-7157
Mailing Address - Fax:650-579-5530
Practice Address - Street 1:720 SS ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4245
Practice Address - Country:US
Practice Address - Phone:650-579-7157
Practice Address - Fax:650-579-5530
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)