Provider Demographics
NPI:1033687801
Name:NEARY, RANDAL SCOTT
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:SCOTT
Last Name:NEARY
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 1:8515 GERHARDT ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-4411
Mailing Address - Country:US
Mailing Address - Phone:588-246-4749
Mailing Address - Fax:
Practice Address - Street 1:50258 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-1374
Practice Address - Country:US
Practice Address - Phone:586-884-4717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI640116816101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional