Provider Demographics
NPI:1619111721
Name:MCDONALD, RANDI NICHOLS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RANDI
Middle Name:NICHOLS
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 EGLIN PKWY
Mailing Address - Street 2:SUITE C-12
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-2306
Mailing Address - Country:US
Mailing Address - Phone:850-613-6677
Mailing Address - Fax:850-613-6993
Practice Address - Street 1:1270 EGLIN PKWY
Practice Address - Street 2:SUITE C-12
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-2306
Practice Address - Country:US
Practice Address - Phone:850-613-6677
Practice Address - Fax:850-613-6993
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60026315103TC0700X
FLPY7940103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical