Provider Demographics
NPI:1972995330
Name:DELISLE, RANDALL DAVID
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:DAVID
Last Name:DELISLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:DELISLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3021
Mailing Address - Street 2:
Mailing Address - City:SHELL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-3021
Mailing Address - Country:US
Mailing Address - Phone:209-815-2526
Mailing Address - Fax:
Practice Address - Street 1:2178 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4535
Practice Address - Country:US
Practice Address - Phone:805-781-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122536106H00000X
CA98280106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist