Provider Demographics
NPI:1871659177
Name:WEISS, RANDY M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:RANDY
Middle Name:M
Last Name:WEISS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 E SHEA BLVD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3074
Mailing Address - Country:US
Mailing Address - Phone:602-242-5400
Mailing Address - Fax:602-277-1076
Practice Address - Street 1:4545 E SHEA BLVD
Practice Address - Street 2:SUITE 235
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3074
Practice Address - Country:US
Practice Address - Phone:602-242-5400
Practice Address - Fax:602-277-1076
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW100541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ67689Medicare ID - Type Unspecified