Provider Demographics
NPI:1043633902
Name:THOMAS, RANDALL JR
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:THOMAS
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 MCMILLAN AVE STE 164
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6768
Mailing Address - Country:US
Mailing Address - Phone:805-438-3890
Mailing Address - Fax:
Practice Address - Street 1:2975 MCMILLAN AVE STE 164
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6768
Practice Address - Country:US
Practice Address - Phone:805-438-3890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34530167G00000X
373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician