Provider Demographics
NPI:1790779775
Name:SMITH, MARK RANDALL (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RANDALL
Last Name:SMITH
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 1:904 HWY 15 SOUTH FRONTAGE RD.
Mailing Address - Street 2:SUITE H
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350
Mailing Address - Country:US
Mailing Address - Phone:320-587-2939
Mailing Address - Fax:320-864-1927
Practice Address - Street 1:904 HWY 15 SOUTH FRONTAGE RD.
Practice Address - Street 2:SUITE H
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350
Practice Address - Country:US
Practice Address - Phone:320-587-2939
Practice Address - Fax:320-864-1927
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2907103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
24981OtherHEALTH PARTNERS
6120057OtherUNITED BEH HEALTH
MN262248300Medicaid
0004049OtherAETNA
112964OtherCHOICE PLUS
030701079OtherPRIME WEST HEALTH SYST
990991000146OtherPREFERRED ONE/BHP
MN53308SMOtherBC
IA98520OtherBC
MN115129OtherUCARE
R05215Medicare UPIN
6120057OtherUNITED BEH HEALTH