Provider Demographics
NPI:1235608084
Name:SHIVELY, RANDALL KENNETH (PHD, LICDC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:KENNETH
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:PHD, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 STELLA CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1011
Mailing Address - Country:US
Mailing Address - Phone:614-252-8402
Mailing Address - Fax:614-252-5326
Practice Address - Street 1:2100 STELLA CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1011
Practice Address - Country:US
Practice Address - Phone:614-252-8402
Practice Address - Fax:614-252-5326
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH975850101YA0400X
OH4374103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)