Provider Demographics
NPI:1699192922
Name:HARVEY, RANDALL (PC C1200275)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:HARVEY
Suffix:
Gender:M
Credentials:PC C1200275
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1928
Mailing Address - Country:US
Mailing Address - Phone:937-280-2000
Mailing Address - Fax:937-280-2051
Practice Address - Street 1:300 W NATIONAL RD
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-1928
Practice Address - Country:US
Practice Address - Phone:937-280-2000
Practice Address - Fax:937-280-2051
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1200275101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3116635668Medicaid