Provider Demographics
NPI:1598962987
Name:RANDALL, TIM L (LAC)
Entity Type:Individual
Prefix:MR
First Name:TIM
Middle Name:L
Last Name:RANDALL
Suffix:
Gender:M
Credentials:LAC
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:YPSILANTI
Mailing Address - State:ND
Mailing Address - Zip Code:58497-0286
Mailing Address - Country:US
Mailing Address - Phone:701-489-3289
Mailing Address - Fax:
Practice Address - Street 1:300 2ND AVE NE
Practice Address - Street 2:SUITE 221
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3373
Practice Address - Country:US
Practice Address - Phone:701-252-5398
Practice Address - Fax:701-252-5398
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1102101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)