Provider Demographics
NPI:1972872877
Name:PEMBERTON, RANDALL KEITH (BA, BHRS)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:KEITH
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:BA, BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROCK ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-2734
Mailing Address - Country:US
Mailing Address - Phone:405-262-5422
Mailing Address - Fax:405-262-5422
Practice Address - Street 1:203 S ROCK ISLAND AVE
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2734
Practice Address - Country:US
Practice Address - Phone:405-262-5422
Practice Address - Fax:405-262-5422
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health