Provider Demographics
NPI:1346679685
Name:CALLAWAY, RANDALL (MS, MFT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:CALLAWAY
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:
Other - First Name:RANDALL
Other - Middle Name:
Other - Last Name:CALLAWAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, MFT
Mailing Address - Street 1:5584 S FORT APACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-7657
Mailing Address - Country:US
Mailing Address - Phone:702-743-3305
Mailing Address - Fax:
Practice Address - Street 1:5584 S FORT APACHE RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7657
Practice Address - Country:US
Practice Address - Phone:702-743-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1346679685Medicaid