Provider Demographics
NPI:1427567676
Name:RANDALL, THURSTON JR (CASAC)
Entity Type:Individual
Prefix:MR
First Name:THURSTON
Middle Name:
Last Name:RANDALL
Suffix:JR
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LEONARD ST. SUITE 19Q
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206
Mailing Address - Country:US
Mailing Address - Phone:347-863-9001
Mailing Address - Fax:
Practice Address - Street 1:250 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451
Practice Address - Country:US
Practice Address - Phone:718-292-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21943101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY21943Medicaid