Provider Demographics
NPI:1639840499
Name:DITMORE, RANDY RANDALL (LPC)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:RANDALL
Last Name:DITMORE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:RANDALL
Other - Last Name:DITMORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:5302 WATER TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-2243
Mailing Address - Country:US
Mailing Address - Phone:281-989-3908
Mailing Address - Fax:
Practice Address - Street 1:5302 WATER TERRACE LN
Practice Address - Street 2:
Practice Address - City:FULSHEAR
Practice Address - State:TX
Practice Address - Zip Code:77441-2243
Practice Address - Country:US
Practice Address - Phone:281-989-3908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health