Provider Demographics
NPI:1134683360
Name:GAINES, RANDY ELIJAH
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:ELIJAH
Last Name:GAINES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 KINGSBRIDGE TER APT B62
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-7462
Mailing Address - Country:US
Mailing Address - Phone:347-522-7740
Mailing Address - Fax:
Practice Address - Street 1:2775 KINGSBRIDGE TER APT B62
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-7462
Practice Address - Country:US
Practice Address - Phone:347-522-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health