Provider Demographics
NPI:1508299819
Name:RANDALL, JOHN WILSON JR (SW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILSON
Last Name:RANDALL
Suffix:JR
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 N DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3829
Mailing Address - Country:US
Mailing Address - Phone:256-520-5804
Mailing Address - Fax:
Practice Address - Street 1:210 POSTWOOD CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-6620
Practice Address - Country:US
Practice Address - Phone:256-520-5804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-11
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1720C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical