Provider Demographics
NPI:1093794208
Name:KAHAN, RANDALL MARTIN (LCSW, LCDC, BCD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:MARTIN
Last Name:KAHAN
Suffix:
Gender:M
Credentials:LCSW, LCDC, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 SARATOGA LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-1863
Mailing Address - Country:US
Mailing Address - Phone:817-307-9178
Mailing Address - Fax:
Practice Address - Street 1:3337 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-4603
Practice Address - Country:US
Practice Address - Phone:817-274-0981
Practice Address - Fax:817-274-9712
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9121101YA0400X
TX009151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
58318OtherAMERICAN BOARD OF EXAMINERS IN CLINICAL SOCIAL WORK BCD
TX071278801Medicaid