Provider Demographics
NPI:1629419825
Name:RANDALL, KEVIN AURELIUS II (BS)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:AURELIUS
Last Name:RANDALL
Suffix:II
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 NW 9TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-2420
Mailing Address - Country:US
Mailing Address - Phone:405-618-0558
Mailing Address - Fax:
Practice Address - Street 1:1808 NW 9TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-2420
Practice Address - Country:US
Practice Address - Phone:405-618-0558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health