Healthcare Provider Details

I. General information

NPI: 1457481244
Provider Name (Legal Business Name): RANDALL ROY HETTICH PH.D., L.M.F.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 W GARVEY AVE N SUITE 100
WEST COVINA CA
91790-2138
US

IV. Provider business mailing address

1511 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

V. Phone/Fax

Practice location:
  • Phone: 626-960-4844
  • Fax: 626-856-3010
Mailing address:
  • Phone: 626-960-4844
  • Fax: 626-856-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC41087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: