Provider Demographics
NPI:1790095313
Name:RANDELL, KING RICHARD (LPC, CADAC, ICADC)
Entity Type:Individual
Prefix:MR
First Name:KING
Middle Name:RICHARD
Last Name:RANDELL
Suffix:
Gender:M
Credentials:LPC, CADAC, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-6718
Mailing Address - Country:US
Mailing Address - Phone:520-586-0800
Mailing Address - Fax:520-586-0116
Practice Address - Street 1:590 S OCOTILLO AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6405
Practice Address - Country:US
Practice Address - Phone:520-586-7080
Practice Address - Fax:520-586-6104
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCADAC-1607101YA0400X
AZICADC-122108101YA0400X
AZLPC-1244101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)