Provider Demographics
NPI:1043693369
Name:RANDALL, TRISTAN HOWARD
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:HOWARD
Last Name:RANDALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15497 W SAND ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2910
Mailing Address - Country:US
Mailing Address - Phone:442-327-9311
Mailing Address - Fax:442-327-9315
Practice Address - Street 1:29995 TECHNOLOGY DR STE 306
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2634
Practice Address - Country:US
Practice Address - Phone:442-327-9311
Practice Address - Fax:442-327-9315
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1044131041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty