Provider Demographics
NPI:1689232860
Name:CHASE, RANDYL SHANE
Entity Type:Individual
Prefix:
First Name:RANDYL
Middle Name:SHANE
Last Name:CHASE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-3270
Mailing Address - Country:US
Mailing Address - Phone:315-573-6689
Mailing Address - Fax:
Practice Address - Street 1:80 STATE HIGHWAY 310 STE 1
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1493
Practice Address - Country:US
Practice Address - Phone:315-386-2189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35354101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)