Provider Demographics
NPI:1922110253
Name:SMITH, RANDALL B (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:B
Last Name:SMITH
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 1:1375 SUTTER ST STE 304
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-5466
Mailing Address - Country:US
Mailing Address - Phone:415-563-3190
Mailing Address - Fax:415-563-2789
Practice Address - Street 1:1375 SUTTER ST STE 304
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5466
Practice Address - Country:US
Practice Address - Phone:415-563-3190
Practice Address - Fax:415-563-2789
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5827103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical