Provider Demographics
NPI:1932889193
Name:YATES, RANDOLPH VERNON (LICENSED EDUCATIONAL)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:VERNON
Last Name:YATES
Suffix:
Gender:M
Credentials:LICENSED EDUCATIONAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LIBERTY CT
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-2774
Mailing Address - Country:US
Mailing Address - Phone:530-739-2647
Mailing Address - Fax:
Practice Address - Street 1:15951 LOS GATOS BLVD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-3428
Practice Address - Country:US
Practice Address - Phone:408-358-1853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4074103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool