Provider Demographics
NPI:1033412820
Name:VICKERS, RANDALL STEVEN (MS)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:STEVEN
Last Name:VICKERS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 E TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4981
Mailing Address - Country:US
Mailing Address - Phone:850-681-6543
Mailing Address - Fax:
Practice Address - Street 1:565 E TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4981
Practice Address - Country:US
Practice Address - Phone:850-681-6543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 770101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health