Provider Demographics
NPI:1811346281
Name:WYNGLASS, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:WYNGLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 GATEWAY CENTER WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4550
Mailing Address - Country:US
Mailing Address - Phone:619-398-2156
Mailing Address - Fax:
Practice Address - Street 1:2029 CENTURY PARK E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2901
Practice Address - Country:US
Practice Address - Phone:619-804-9157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132426106H00000X, 101YM0800X
101YM0800X, 390200000X
CAAMFT104157106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program