Provider Demographics
NPI:1467148809
Name:GANN, RANDLE BLAKE (LMSW)
Entity Type:Individual
Prefix:MR
First Name:RANDLE
Middle Name:BLAKE
Last Name:GANN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8751 HARDING DR
Mailing Address - Street 2:
Mailing Address - City:COTTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35453-1311
Mailing Address - Country:US
Mailing Address - Phone:205-826-2127
Mailing Address - Fax:
Practice Address - Street 1:3701 LOOP RD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5015
Practice Address - Country:US
Practice Address - Phone:205-554-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3279G104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker