Provider Demographics
NPI:1477968881
Name:BURCHAM, RANDALL SCOTT (MSSW LCSW)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:SCOTT
Last Name:BURCHAM
Suffix:
Gender:M
Credentials:MSSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:3201 W KEISER
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3467
Practice Address - Country:US
Practice Address - Phone:870-622-0592
Practice Address - Fax:870-622-0782
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1055-C1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227809719Medicaid
AR50461OtherBCBS