Provider Demographics
NPI:1467822023
Name:SHANE, RANDIE (IMFT)
Entity Type:Individual
Prefix:
First Name:RANDIE
Middle Name:
Last Name:SHANE
Suffix:
Gender:F
Credentials:IMFT
Other - Prefix:
Other - First Name:RANDIE
Other - Middle Name:SHANE
Other - Last Name:TOLLEFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IMFT
Mailing Address - Street 1:2460 FAIRMOUNT BLVD, #326
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106
Mailing Address - Country:US
Mailing Address - Phone:917-478-1254
Mailing Address - Fax:
Practice Address - Street 1:2460 FAIRMOUNT BLVD, #326
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:917-478-1254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001248106H00000X
OHF.1700018106H00000X
OHF1700018106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0239788Medicaid