Provider Demographics
NPI:1881002368
Name:RANDALL, EMILY A (LCSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:RANDALL
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 1:2 OLD NEW MILFORD ROAD
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804
Mailing Address - Country:US
Mailing Address - Phone:203-775-2583
Mailing Address - Fax:203-775-2863
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2310
Practice Address - Country:US
Practice Address - Phone:203-574-9000
Practice Address - Fax:203-574-9006
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2218104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060669107OtherHEALTHYCT WELLMORE GRP/FACILITY
CT060669107OtherUBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CT13671806OtherCAQH
CTPENDINGMedicaid
CT060669107OtherANTHEM BEHAVIORRAL HEALTH WELLMORE GRP/FACILITY
CT060669107OtherOPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY
CTNOT ELIGIBLEOtherBEACON HEALTH STRATEGIES
CT060669107OtherUBH-OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY
CT060669107OtherAETNA BEHAVIORAL HEALTH WELLMORE GRP/FACILITY
CTNOT ELIGIBLEOtherMHN TRICARE NORTH
CTPENDINGOtherCIGNA BEHAVIORAL HEALTH
CTNOT ELIGIBLEOtherMHN-MANAGED HEALTH NETWORK
CTNOT ELIGIBLEOtherMHN TRICARE NORTH