Provider Demographics
NPI:1750658233
Name:GATES, RANDALL (MFT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:GATES
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 1:333 OHIO ST
Mailing Address - Street 2:NONE
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-4211
Mailing Address - Country:US
Mailing Address - Phone:310-422-7101
Mailing Address - Fax:
Practice Address - Street 1:16542 VENTURA BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2005
Practice Address - Country:US
Practice Address - Phone:310-422-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 50209101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health