Provider Demographics
NPI:1982931143
Name:RANDALL, JULIE ANN (CMT)
Entity Type:Individual
Prefix:MS
First Name:JULIE ANN
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5313
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-0313
Mailing Address - Country:US
Mailing Address - Phone:650-483-4627
Mailing Address - Fax:
Practice Address - Street 1:161 W 25TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2268
Practice Address - Country:US
Practice Address - Phone:650-483-4627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X, 174H00000X
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174H00000XOther Service ProvidersHealth Educator