Provider Demographics
NPI:1265861959
Name:GENNARO, RANDI JANELLE (MSC, LAC)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:JANELLE
Last Name:GENNARO
Suffix:
Gender:F
Credentials:MSC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4114
Mailing Address - Country:US
Mailing Address - Phone:602-285-5550
Mailing Address - Fax:
Practice Address - Street 1:4414 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-4114
Practice Address - Country:US
Practice Address - Phone:602-285-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC- 13883101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor