Provider Demographics
NPI:1366950032
Name:RANDOLPH, DIANA MARIE
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 N SANDALWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3848
Mailing Address - Country:US
Mailing Address - Phone:909-838-6408
Mailing Address - Fax:
Practice Address - Street 1:1124 N SANDALWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-3848
Practice Address - Country:US
Practice Address - Phone:909-838-6408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
CAXXXXXXXXXX101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6990202OtherKAISER