Healthcare Provider Details

I. General information

NPI: 1356064133
Provider Name (Legal Business Name): RANDIROSE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 BARRANCA PKWY
IRVINE CA
92604-4652
US

IV. Provider business mailing address

12070 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3771
US

V. Phone/Fax

Practice location:
  • Phone: 626-485-4150
  • Fax:
Mailing address:
  • Phone: 562-777-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: