Provider Demographics
NPI:1730106212
Name:RANDALL, RANDALL C (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:C
Last Name:RANDALL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 BRICKYARD RD APT 1203
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2537
Mailing Address - Country:US
Mailing Address - Phone:801-580-3823
Mailing Address - Fax:
Practice Address - Street 1:5242 S 4820 W
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-6422
Practice Address - Country:US
Practice Address - Phone:801-966-4251
Practice Address - Fax:801-966-4289
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4809685-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health