Provider Demographics
NPI:1689392557
Name:RANDALL, TROY DAVID
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:DAVID
Last Name:RANDALL
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 1:323 LEGACY LN
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-3300
Mailing Address - Country:US
Mailing Address - Phone:435-850-8471
Mailing Address - Fax:
Practice Address - Street 1:2356 N 400 E STE 203
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3409
Practice Address - Country:US
Practice Address - Phone:435-850-2547
Practice Address - Fax:435-843-7438
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool