Provider Demographics
NPI:1164518379
Name:ANDERSON, RANDI LEE (JD, LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:LEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:JD, LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E 74TH ST
Mailing Address - Street 2:5C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3712
Mailing Address - Country:US
Mailing Address - Phone:646-232-9633
Mailing Address - Fax:
Practice Address - Street 1:1397 2ND AVE
Practice Address - Street 2:#123
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4505
Practice Address - Country:US
Practice Address - Phone:646-232-9633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069225-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker