Provider Demographics
NPI:1407124670
Name:AILES, RANDALL GARDNER (MA, LMSW, LPC)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:GARDNER
Last Name:AILES
Suffix:
Gender:M
Credentials:MA, LMSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-2544
Mailing Address - Country:US
Mailing Address - Phone:269-929-7784
Mailing Address - Fax:269-945-3182
Practice Address - Street 1:1425 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-2544
Practice Address - Country:US
Practice Address - Phone:269-929-7784
Practice Address - Fax:269-945-3182
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010143891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical