Provider Demographics
NPI:1003613886
Name:RANDALL, BURL THOMAS III
Entity type:Individual
Prefix:
First Name:BURL
Middle Name:THOMAS
Last Name:RANDALL
Suffix:III
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BURL
Other - Middle Name:THOMAS
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1130 E INDEPENDENCE ST APT 515
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-4174
Mailing Address - Country:US
Mailing Address - Phone:405-584-2812
Mailing Address - Fax:
Practice Address - Street 1:1130 E INDEPENDENCE ST APT 515
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-4174
Practice Address - Country:US
Practice Address - Phone:405-584-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)