Provider Demographics
NPI:1376356196
Name:IACOVETTA, RANDY MICHAEL-IGNACIO (MA)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:MICHAEL-IGNACIO
Last Name:IACOVETTA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W LAMBERT RD STE 210
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-3940
Mailing Address - Country:US
Mailing Address - Phone:949-377-0220
Mailing Address - Fax:
Practice Address - Street 1:595 W LAMBERT RD STE 210
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3940
Practice Address - Country:US
Practice Address - Phone:949-377-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT139991106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist