Provider Demographics
NPI:1912353780
Name:RANDALL, CAMERON EBY
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:EBY
Last Name:RANDALL
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 1:14251 DANIELSON ST
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-8818
Mailing Address - Country:US
Mailing Address - Phone:858-699-7579
Mailing Address - Fax:858-726-6021
Practice Address - Street 1:14251 DANIELSON ST
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-8818
Practice Address - Country:US
Practice Address - Phone:858-699-7579
Practice Address - Fax:858-726-6021
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396085718Medicaid