Provider Demographics
NPI:1407052400
Name:RANDALL, TYANTHA G (LCSW-C)
Entity Type:Individual
Prefix:
First Name:TYANTHA
Middle Name:G
Last Name:RANDALL
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 1:104 WILLIAMSPORT CIR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-6400
Mailing Address - Country:US
Mailing Address - Phone:443-859-8699
Mailing Address - Fax:443-859-8747
Practice Address - Street 1:104 WILLIAMSPORT CIR
Practice Address - Street 2:SUITE C
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-6400
Practice Address - Country:US
Practice Address - Phone:443-859-8699
Practice Address - Fax:443-859-8747
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD131171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD744800100Medicaid