MEDICARE: MISS KELLY MAY RANDALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1447912605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KELLY MAY RANDALL

Provider Business Mailing Address
First Line	:	2205 GARDENA AVE
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95204-4613
Country	:	US
Telephone Number	:	209-684-2803
Fax Number	:

Provider Business Practice Location Address
First Line	:	12437 LEWIS ST
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-4673
Country	:	US
Telephone Number	:	805-691-9483
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2021
Last Update Date	:	10/06/2021

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Directions to “ MISS KELLY MAY RANDALL ” Practice Location

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