Provider Demographics
NPI:1558944108
Name:RANDALL, BYRON JR (CPRP)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:
Last Name:RANDALL
Suffix:JR
Gender:M
Credentials:CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6340 SECURITY BLVD STE B34
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-5173
Mailing Address - Country:US
Mailing Address - Phone:443-912-4460
Mailing Address - Fax:
Practice Address - Street 1:6340 SECURITY BLVD
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-5173
Practice Address - Country:US
Practice Address - Phone:410-912-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-02
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health