Basic Information
| Provider Information | |||||||||
| NPI: | 1366566697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVSHALOMOV | ||||||||
| FirstName: | RANDI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, MFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAFMAN | ||||||||
| OtherFirstName: | RANDI | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA, MFT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4026 PECK RD | ||||||||
| Address2: | #204 | ||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917322247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264440539 | ||||||||
| FaxNumber: | 6264447990 | ||||||||
| Practice Location | |||||||||
| Address1: | 4026 PECK RD | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917322247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264440539 | ||||||||
| FaxNumber: | 6264447990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC13289 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | GRA0721 | 01 | CA | STAFF CODE | OTHER |