Provider Demographics
NPI:1609283613
Name:DAME, RANDAL
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:DAME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 LEAHY ST STE 210B
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5542
Mailing Address - Country:US
Mailing Address - Phone:231-672-3305
Mailing Address - Fax:231-672-8407
Practice Address - Street 1:1675 LEAHY ST STE 210B
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5542
Practice Address - Country:US
Practice Address - Phone:231-855-0381
Practice Address - Fax:231-672-8407
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-04741101YA0400X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)