Provider Demographics
NPI:1255161576
Name:RANDALL, SHELBI L (LAC)
Entity type:Individual
Prefix:
First Name:SHELBI
Middle Name:L
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1968 HIGHWAY 31 N
Mailing Address - Street 2:
Mailing Address - City:BEEBE
Mailing Address - State:AR
Mailing Address - Zip Code:72012-9784
Mailing Address - Country:US
Mailing Address - Phone:512-718-8517
Mailing Address - Fax:
Practice Address - Street 1:60 W SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1822
Practice Address - Country:US
Practice Address - Phone:479-695-1240
Practice Address - Fax:479-695-1242
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2407009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health