Provider Demographics
NPI:1932548526
Name:RANDELMAN, MIRELLA FLORES (PHD)
Entity Type:Individual
Prefix:
First Name:MIRELLA
Middle Name:FLORES
Last Name:RANDELMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3876 GOLF VILLAGE LOOP APT 5
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4087
Mailing Address - Country:US
Mailing Address - Phone:561-603-2027
Mailing Address - Fax:
Practice Address - Street 1:287 LORTON AVE
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4203
Practice Address - Country:US
Practice Address - Phone:877-505-7147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005591103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling