Provider Demographics
NPI:1689285694
Name:HIATT, RANDY EUGENE (EDD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:EUGENE
Last Name:HIATT
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2933 BOXWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5907
Mailing Address - Country:US
Mailing Address - Phone:843-206-2921
Mailing Address - Fax:843-661-6705
Practice Address - Street 1:2145B HOFFMEYER RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4015
Practice Address - Country:US
Practice Address - Phone:843-669-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1033101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1033OtherSTATE LICENSE