Provider Demographics
NPI:1942343751
Name:RANDAHL, PATRICIA WELLS (MA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:WELLS
Last Name:RANDAHL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-5425
Mailing Address - Country:US
Mailing Address - Phone:253-968-4518
Mailing Address - Fax:253-968-6888
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-8330
Practice Address - Country:US
Practice Address - Phone:360-373-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001546106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA911020106A9OtherKITSAP PHYSICIANS SERVICE