Provider Demographics
NPI:1972271567
Name:WILLARD, RANDI NICOLE
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:NICOLE
Last Name:WILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14765 HERMAN HAUVER RD
Mailing Address - Street 2:
Mailing Address - City:SABILLASVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21780-8502
Mailing Address - Country:US
Mailing Address - Phone:240-818-1491
Mailing Address - Fax:
Practice Address - Street 1:5300 WESTVIEW DR STE 200
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8303
Practice Address - Country:US
Practice Address - Phone:240-247-0977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician