Healthcare Provider Details

I. General information

NPI: 1336287226
Provider Name (Legal Business Name): DYANE L RANDLE IMF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 TUOLUMNE ST
VALLEJO CA
94590-4641
US

IV. Provider business mailing address

1701 KEESLER CIR
SUISUN CITY CA
94585-6326
US

V. Phone/Fax

Practice location:
  • Phone: 707-648-8121
  • Fax: 707-648-8129
Mailing address:
  • Phone: 707-761-7665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number73635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: