Provider Demographics
NPI:1184854606
Name:RANDALL, IDA JOYCE
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:JOYCE
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 1:2860 S CIRCLE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4133
Mailing Address - Country:US
Mailing Address - Phone:719-634-1240
Mailing Address - Fax:719-540-0174
Practice Address - Street 1:2860 S CIRCLE DR STE 220
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4133
Practice Address - Country:US
Practice Address - Phone:719-634-1240
Practice Address - Fax:719-540-0174
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CO1745-01101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health