Provider Demographics
NPI:1609347509
Name:RANDALL, ERICA (LMSW, LMFT)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LMSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E FAYETTE ST STE 216
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-1943
Mailing Address - Country:US
Mailing Address - Phone:315-433-1500
Mailing Address - Fax:
Practice Address - Street 1:1065 JAMES ST STE 210
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2766
Practice Address - Country:US
Practice Address - Phone:315-481-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001797106H00000X
NY104170104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist