Healthcare Provider Details

I. General information

NPI: 1750642195
Provider Name (Legal Business Name): MR. RANDY G SUTTLES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 SCENIC AVE
BERKELEY CA
94709-1395
US

IV. Provider business mailing address

1820 SCENIC AVE
BERKELEY CA
94709-1395
US

V. Phone/Fax

Practice location:
  • Phone: 510-548-7270
  • Fax:
Mailing address:
  • Phone: 510-548-7270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: