Basic Information
| Provider Information | |||||||||
| NPI: | 1457481244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HETTICH | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | ROY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., L.M.F.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1511 W GARVEY AVE N | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917902138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269604844 | ||||||||
| FaxNumber: | 6268563010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 W GARVEY AVE N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917902138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269604844 | ||||||||
| FaxNumber: | 6268563010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC41087 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.