Provider Demographics
NPI:1821121716
Name:GRODI, RANDY H (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:H
Last Name:GRODI
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 1:750 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-1433
Mailing Address - Country:US
Mailing Address - Phone:734-639-2262
Mailing Address - Fax:734-264-4114
Practice Address - Street 1:750 S MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1433
Practice Address - Country:US
Practice Address - Phone:734-639-2262
Practice Address - Fax:734-264-4114
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007925103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E84509OtherBLUE CROSS PROVIDER ID
MI0E84509OtherBLUE CROSS PROVIDER ID