Provider Demographics
NPI:1528398336
Name:WHITTLES, RANDY LEE JR (PHD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:LEE
Last Name:WHITTLES
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3634
Mailing Address - Country:US
Mailing Address - Phone:217-373-2428
Mailing Address - Fax:
Practice Address - Street 1:830 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4734
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical