Provider Demographics
NPI:1336667336
Name:RANDALL, MICHAEL JOHN (3747P1801X)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:RANDALL
Suffix:
Gender:M
Credentials:3747P1801X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 1/2 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-3034
Mailing Address - Country:US
Mailing Address - Phone:937-397-3919
Mailing Address - Fax:
Practice Address - Street 1:1109 MEAD RD
Practice Address - Street 2:
Practice Address - City:BELLBROOK
Practice Address - State:OH
Practice Address - Zip Code:45305-8747
Practice Address - Country:US
Practice Address - Phone:937-973-9199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04412833747P1801X
OHLCDCII.161340101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)