Provider Demographics
NPI:1497803027
Name:HART, RANDOLPH LEE (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:LEE
Last Name:HART
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CLUB RD STE 120
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2439
Mailing Address - Country:US
Mailing Address - Phone:541-393-5983
Mailing Address - Fax:541-393-5984
Practice Address - Street 1:66 CLUB RD STE 120
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2439
Practice Address - Country:US
Practice Address - Phone:541-393-5983
Practice Address - Fax:541-393-5984
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62771041C0700X
OR02R07101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210831Medicaid
OR500663524Medicaid
OR210831Medicaid