Provider Demographics
NPI:1417654864
Name:RANDALL, SHAUNTA SHANELL ((BS) PSYCHOLOGY)
Entity Type:Individual
Prefix:MS
First Name:SHAUNTA
Middle Name:SHANELL
Last Name:RANDALL
Suffix:
Gender:F
Credentials:(BS) PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:77 PINEMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-9400
Mailing Address - Country:US
Mailing Address - Phone:228-800-1502
Mailing Address - Fax:
Practice Address - Street 1:9 ROUX 61 DR STE C
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-2176
Practice Address - Country:US
Practice Address - Phone:601-897-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health