Provider Demographics
NPI:1699010611
Name:SMITH, RANDALL S I (LCDC)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:S
Last Name:SMITH
Suffix:I
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 LAKE WASHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5178
Mailing Address - Country:US
Mailing Address - Phone:806-438-8923
Mailing Address - Fax:
Practice Address - Street 1:8402 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-4595
Practice Address - Country:US
Practice Address - Phone:512-697-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11317101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)