Provider Demographics
NPI:1790130052
Name:SMALL, RANDI (AT, ATC)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 N SQUIRREL RD
Mailing Address - Street 2:ATHLETICS CENTER
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48309-4402
Mailing Address - Country:US
Mailing Address - Phone:248-370-3132
Mailing Address - Fax:248-370-4255
Practice Address - Street 1:2200 N SQUIRREL RD
Practice Address - Street 2:ATHLETICS CENTER
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48309-4402
Practice Address - Country:US
Practice Address - Phone:248-370-3132
Practice Address - Fax:248-370-4255
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010015012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer