Healthcare Provider Details

I. General information

NPI: 1285549121
Provider Name (Legal Business Name): KIMINI RANDALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 GREAT AMERICA PKWY STE SANTA
SANTA CLARA CA
95054-1122
US

IV. Provider business mailing address

1454 36TH AVE
OAKLAND CA
94601-3559
US

V. Phone/Fax

Practice location:
  • Phone: 408-562-6123
  • Fax:
Mailing address:
  • Phone: 408-562-6123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: