Provider Demographics
NPI:1518074921
Name:RANDALL, TANA V (LICSW)
Entity Type:Individual
Prefix:
First Name:TANA
Middle Name:V
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 286
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:VT
Mailing Address - Zip Code:05468-0286
Mailing Address - Country:US
Mailing Address - Phone:802-343-1614
Mailing Address - Fax:
Practice Address - Street 1:56 W TWIN OAKS TER
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7106
Practice Address - Country:US
Practice Address - Phone:802-847-3333
Practice Address - Fax:802-847-1424
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00009971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1011510Medicaid
VTVN3885Medicare ID - Type Unspecified
VTOTH000Medicare UPIN