Provider Demographics
NPI:1336313543
Name:RANDEL, MARY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:RANDEL
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 1:76 LAKEWOOD BLVD
Mailing Address - Street 2:APT 2
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3714
Mailing Address - Country:US
Mailing Address - Phone:516-448-4713
Mailing Address - Fax:
Practice Address - Street 1:1880 DUTCH BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-4246
Practice Address - Country:US
Practice Address - Phone:516-326-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2010-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017487235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist