Provider Demographics
NPI:1508496092
Name:WALKER, RANDALL SCOTT (LMBT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:WALKER
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4732 LEBANON RD STE D
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9112
Mailing Address - Country:US
Mailing Address - Phone:704-763-2059
Mailing Address - Fax:
Practice Address - Street 1:4732 LEBANON RD STE D
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-9112
Practice Address - Country:US
Practice Address - Phone:704-763-2059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08381225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08381OtherNORTH CAROLINA BOARD OF MASSAGE & BODYWORK THERAPY