Provider Demographics
NPI:1093028508
Name:RANDALL, ULRIKE
Entity Type:Individual
Prefix:
First Name:ULRIKE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 GARRETT WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5155
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-233-1695
Practice Address - Street 1:2055 GARRETT WAY STE 1
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5155
Practice Address - Country:US
Practice Address - Phone:208-236-1600
Practice Address - Fax:208-233-1695
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health