Provider Demographics
NPI:1972558302
Name:NAYLOR, RANDY (LICSW, LP)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:NAYLOR
Suffix:
Gender:M
Credentials:LICSW, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2473
Mailing Address - Country:US
Mailing Address - Phone:651-385-6180
Mailing Address - Fax:651-385-6195
Practice Address - Street 1:426 WEST AVE
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2473
Practice Address - Country:US
Practice Address - Phone:651-385-6180
Practice Address - Fax:651-385-6195
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1609103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
01013344OtherPREFERRED ONE
117956OtherU-CARE
MN247057800Medicaid
62-69127OtherMEDICA
61Q73NAOtherBX/BS
5115551OtherAETNA
855661013344OtherPREFERREDONE ADMINISTRATI