Provider Demographics
NPI:1023592771
Name:RANDALL, NICOLE RG (LCSW CADC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RG
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LCSW CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 MAIN ST FL 3
Mailing Address - Street 2:
Mailing Address - City:BAR HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04609-1648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:322 MAIN ST
Practice Address - Street 2:
Practice Address - City:BAR HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04609-1648
Practice Address - Country:US
Practice Address - Phone:207-288-8604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC6664101YA0400X
MELC173261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)