Provider Demographics
NPI:1235647264
Name:RANDALL, LA 'TOYA DENISE
Entity Type:Individual
Prefix:
First Name:LA 'TOYA
Middle Name:DENISE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LA 'TOYA
Other - Middle Name:DENISE
Other - Last Name:LOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 WARRIOR LN
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-8685
Mailing Address - Country:US
Mailing Address - Phone:573-888-5925
Mailing Address - Fax:
Practice Address - Street 1:3001 WARRIOR LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8685
Practice Address - Country:US
Practice Address - Phone:573-888-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician