Healthcare Provider Details

I. General information

NPI: 1306909254
Provider Name (Legal Business Name): MONIQUE RANDOLPH CAODC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 HOWARD ST
SAN FRANCISCO CA
94103-2638
US

IV. Provider business mailing address

1380 HOWARD ST
SAN FRANCISCO CA
94103-2638
US

V. Phone/Fax

Practice location:
  • Phone: 628-754-9142
  • Fax: 628-754-9591
Mailing address:
  • Phone: 628-754-9142
  • Fax: 415-975-9932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1913501
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1913501
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: