Provider Demographics
NPI:1437859733
Name:RANDBY, MICKALA TAYLOR
Entity Type:Individual
Prefix:
First Name:MICKALA
Middle Name:TAYLOR
Last Name:RANDBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 N TALMAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2376
Mailing Address - Country:US
Mailing Address - Phone:224-567-9347
Mailing Address - Fax:
Practice Address - Street 1:8707 SKOKIE BLVD STE 310
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2281
Practice Address - Country:US
Practice Address - Phone:847-568-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.106595104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150.106595OtherLSW