Provider Demographics
NPI:1184665762
Name:RANDALL-BLY, KRISTA LYNNE (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYNNE
Last Name:RANDALL-BLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1914
Mailing Address - Country:US
Mailing Address - Phone:814-454-4530
Mailing Address - Fax:814-459-6678
Practice Address - Street 1:1202 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1914
Practice Address - Country:US
Practice Address - Phone:814-455-7222
Practice Address - Fax:814-456-2375
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW007945L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000641OtherCIGNA
PA380239OtherHIGHMARK PROVIDER NUMBER
PA465173OtherVALUE OPTIONS
PA465173OtherVALUE OPTIONS
PA1000641OtherCIGNA