Provider Demographics
NPI:1003326653
Name:CABLE, RANDY WAYNE II (LISW, LICDC, PRS)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:WAYNE
Last Name:CABLE
Suffix:II
Gender:M
Credentials:LISW, LICDC, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 STANLEY ST
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-3148
Mailing Address - Country:US
Mailing Address - Phone:740-237-4981
Mailing Address - Fax:877-325-2816
Practice Address - Street 1:323 MARION PIKE STE 1
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2958
Practice Address - Country:US
Practice Address - Phone:740-237-4981
Practice Address - Fax:877-325-2816
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHAPS.003697175T00000X
OHI.24053561041C0700X, 1041C0700X
OHLICDC.162366101YA0400X
OHQMHS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0481281Medicaid