Provider Demographics
NPI:1770820300
Name:RANDALL, MELINDA LUCILLE (LADC LSW)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:LUCILLE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LADC LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 O ST
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-3251
Mailing Address - Country:US
Mailing Address - Phone:775-787-9411
Mailing Address - Fax:775-787-9445
Practice Address - Street 1:115 O ST
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-3251
Practice Address - Country:US
Practice Address - Phone:775-787-9411
Practice Address - Fax:775-787-9445
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV703101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV10Medicaid