Provider Demographics
NPI:1134558794
Name:RANDALL, MELISSA (MS, LCGC)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:637 LUCAS AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1997
Mailing Address - Country:US
Mailing Address - Phone:213-977-9704
Mailing Address - Fax:213-977-9714
Practice Address - Street 1:637 LUCAS AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1997
Practice Address - Country:US
Practice Address - Phone:213-977-9704
Practice Address - Fax:213-977-9714
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC000357170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS