Provider Demographics
NPI:1457094062
Name:RANDLES, TAZ WILLIAM (DMIN, MED)
Entity Type:Individual
Prefix:DR
First Name:TAZ
Middle Name:WILLIAM
Last Name:RANDLES
Suffix:
Gender:M
Credentials:DMIN, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 MINNIS RD NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37323-5236
Mailing Address - Country:US
Mailing Address - Phone:423-715-2616
Mailing Address - Fax:
Practice Address - Street 1:729 MINNIS RD NE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37323-5236
Practice Address - Country:US
Practice Address - Phone:423-715-2616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000590101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health