Provider Demographics
NPI:1073641510
Name:KORELL, RANDI JO (MS LCPC)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:JO
Last Name:KORELL
Suffix:
Gender:F
Credentials:MS LCPC
Other - Prefix:MS
Other - First Name:RANDI
Other - Middle Name:JO
Other - Last Name:WENICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2445 W HWY 52
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617
Mailing Address - Country:US
Mailing Address - Phone:208-365-5393
Mailing Address - Fax:
Practice Address - Street 1:113 N COMMERCIAL
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617
Practice Address - Country:US
Practice Address - Phone:208-398-8473
Practice Address - Fax:208-398-8311
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID359101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010152108OtherBLUE SHIELD
IDQ7486OtherBLUE CROSS