Provider Demographics
NPI:1871647628
Name:RANDALL, DIANE L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
Last Name:RANDALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 DUNDEE AVE
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-4201
Mailing Address - Country:US
Mailing Address - Phone:847-446-7636
Mailing Address - Fax:
Practice Address - Street 1:109 DUNDEE AVE
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-4201
Practice Address - Country:US
Practice Address - Phone:847-446-7636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical