Provider Demographics
NPI:1043596190
Name:ALTMAN, RANDI
Entity Type:Individual
Prefix:DR
First Name:RANDI
Middle Name:
Last Name:ALTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:ALTMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2211 DODGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3012
Mailing Address - Country:US
Mailing Address - Phone:847-212-1360
Mailing Address - Fax:
Practice Address - Street 1:2211 DODGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3012
Practice Address - Country:US
Practice Address - Phone:847-212-1360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490093561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical