Provider Demographics
NPI:1710308788
Name:DANNHEIM, RANDY (LISAC)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:DANNHEIM
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5116 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-7915
Mailing Address - Country:US
Mailing Address - Phone:602-281-6574
Mailing Address - Fax:602-281-6905
Practice Address - Street 1:5116 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7915
Practice Address - Country:US
Practice Address - Phone:602-281-6574
Practice Address - Fax:602-281-6905
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11479101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)