Provider Demographics
NPI:1922638634
Name:SMITH, RANDALL JAY (MA)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 S WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-5650
Mailing Address - Country:US
Mailing Address - Phone:740-819-7054
Mailing Address - Fax:
Practice Address - Street 1:1321 S WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-5650
Practice Address - Country:US
Practice Address - Phone:740-297-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility