Provider Demographics
NPI:1104846575
Name:HULTBERG, RANDY A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:A
Last Name:HULTBERG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 614
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-0614
Mailing Address - Country:US
Mailing Address - Phone:270-886-2205
Mailing Address - Fax:270-886-0392
Practice Address - Street 1:506 HOPKINSVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1104
Practice Address - Country:US
Practice Address - Phone:270-338-5211
Practice Address - Fax:270-338-1624
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000006111041C0700X
KY8041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY804OtherKY BOARD OF SOCIAL WORK