Provider Demographics
NPI:1003996505
Name:RANDALL, KATHLEEN T (LMHC, EMDR)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:T
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LMHC, EMDR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 439
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-0439
Mailing Address - Country:US
Mailing Address - Phone:508-351-6511
Mailing Address - Fax:
Practice Address - Street 1:300 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-2132
Practice Address - Country:US
Practice Address - Phone:508-351-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA367101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALM0896OtherBLUE CROSS/BLUE SHIELD