Provider Demographics
NPI:1083875769
Name:RANDLEMAN, MARY CARMEN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CARMEN
Last Name:RANDLEMAN
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:M CARMEN
Other - Middle Name:
Other - Last Name:RANDLEMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1084
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-1084
Mailing Address - Country:US
Mailing Address - Phone:918-724-6449
Mailing Address - Fax:918-208-0687
Practice Address - Street 1:207 N OAK ST STE 5
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-4602
Practice Address - Country:US
Practice Address - Phone:918-724-6449
Practice Address - Fax:918-208-0687
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X, 106H00000X, 101YM0800X, 101Y00000X, 101YM0800X
OK229640103TS0200X
OK4855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200456660 AMedicaid
OK200378480Medicaid