Provider Demographics
NPI:1821272303
Name:OFTEDAHL, RANDALL VERHDEK
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:VERHDEK
Last Name:OFTEDAHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2150
Mailing Address - Country:US
Mailing Address - Phone:401-338-7277
Mailing Address - Fax:
Practice Address - Street 1:744 PARK AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-2150
Practice Address - Country:US
Practice Address - Phone:401-338-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW01913104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRO53435Medicaid