Provider Demographics
NPI:1477296630
Name:RANDALL, MARIA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 MAGNOLIA LEAF DR
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-2497
Mailing Address - Country:US
Mailing Address - Phone:901-351-4327
Mailing Address - Fax:
Practice Address - Street 1:3240 MAGNOLIA LEAF DR
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2497
Practice Address - Country:US
Practice Address - Phone:901-351-4327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW000000070441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical