Provider Demographics
NPI:1902362767
Name:RANDOW, MARIAH KAY
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:KAY
Last Name:RANDOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:13553 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3256
Practice Address - Country:US
Practice Address - Phone:904-420-7030
Practice Address - Fax:904-297-4064
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-22-62014103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician