Provider Demographics
NPI:1780630814
Name:LAGRONE, RANDY GRAYSON (PHD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:GRAYSON
Last Name:LAGRONE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984185 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-4185
Mailing Address - Country:US
Mailing Address - Phone:402-559-5031
Mailing Address - Fax:
Practice Address - Street 1:984185 NEBRASKA MEDICAL CTR
Practice Address - Street 2:EMILE AT 42ND ST.
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-4185
Practice Address - Country:US
Practice Address - Phone:402-559-5031
Practice Address - Fax:402-559-9592
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE237103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R29863Medicare UPIN
NE269903Medicare ID - Type Unspecified