Provider Demographics
NPI:1609428929
Name:RANDALL, GEORGE JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:RANDALL
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 WOODSON RD APT A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-2896
Mailing Address - Country:US
Mailing Address - Phone:443-750-5500
Mailing Address - Fax:
Practice Address - Street 1:6819 REISTERSTOWN RD STE 203
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-1418
Practice Address - Country:US
Practice Address - Phone:443-438-4584
Practice Address - Fax:443-835-2037
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD143291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty