MEDICARE: RANDY WYNGLASS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	132426	CA
2	101YM0800X	Mental Health Counselor
3	101YM0800X	Mental Health Counselor	132426	CA
4	106H00000X	Marriage & Family Therapist	AMFT104157	CA
5	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1811346281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDY WYNGLASS

Provider Business Mailing Address
First Line	:	995 GATEWAY CENTER WAY STE 300
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-4550
Country	:	US
Telephone Number	:	619-398-2156
Fax Number	:

Provider Business Practice Location Address
First Line	:	2029 CENTURY PARK E
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2901
Country	:	US
Telephone Number	:	619-804-9157
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	05/14/2024

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