Provider Demographics
NPI:1578278321
Name:RANDLE, TELISA R (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:TELISA
Middle Name:R
Last Name:RANDLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8705 BRYAM APT 2002
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77061-2522
Mailing Address - Country:US
Mailing Address - Phone:281-781-5678
Mailing Address - Fax:
Practice Address - Street 1:8705 BRYAM APT 2002
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77061-2522
Practice Address - Country:US
Practice Address - Phone:281-781-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62841101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNONEOtherNONE