Provider Demographics
NPI:1831615467
Name:RANDALL, LILY (PSYD)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 CAMINO DE LOS MARES STE 207A
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2832
Mailing Address - Country:US
Mailing Address - Phone:714-345-5200
Mailing Address - Fax:
Practice Address - Street 1:629 CAMINO DE LOS MARES STE 207A
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2832
Practice Address - Country:US
Practice Address - Phone:714-345-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist