Provider Demographics
NPI:1376736124
Name:RANDLE, PHYLLIS (LCSW-C)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:RANDLE
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MERCANTILE LN
Mailing Address - Street 2:232
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5341
Mailing Address - Country:US
Mailing Address - Phone:301-583-0001
Mailing Address - Fax:301-583-3403
Practice Address - Street 1:1400 MERCANTILE LN
Practice Address - Street 2:232
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5341
Practice Address - Country:US
Practice Address - Phone:301-583-0001
Practice Address - Fax:301-583-3403
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD090621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical