Provider Demographics
NPI:1245354794
Name:SPEYER, GERALD RANDALL (MFT)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:RANDALL
Last Name:SPEYER
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 1:11125 CAMPUS ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3227
Mailing Address - Country:US
Mailing Address - Phone:909-558-4570
Mailing Address - Fax:
Practice Address - Street 1:11125 CAMPUS ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3227
Practice Address - Country:US
Practice Address - Phone:909-558-4570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 42802106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 42802OtherSTATE LICENSE