Provider Demographics
NPI:1508941931
Name:WILLS, RANDY JAMES (MA LP)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:JAMES
Last Name:WILLS
Suffix:
Gender:M
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2346 ABBYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-4245
Mailing Address - Country:US
Mailing Address - Phone:507-351-2920
Mailing Address - Fax:507-385-2090
Practice Address - Street 1:13637 60TH ST SW
Practice Address - Street 2:
Practice Address - City:COKATO
Practice Address - State:MN
Practice Address - Zip Code:55321-4210
Practice Address - Country:US
Practice Address - Phone:320-286-2922
Practice Address - Fax:320-286-2875
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0388103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN58528WIOtherBLUE CROSS OF MN
MN120450OtherBHP
MN720851100Medicaid
MNK535OtherUCARE