Provider Demographics
NPI:1255731055
Name:BLACK, RANDI
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 N COLLEGE PARK ST STE 200
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3639
Mailing Address - Country:US
Mailing Address - Phone:316-351-8517
Mailing Address - Fax:316-260-6494
Practice Address - Street 1:1121 N COLLEGE PARK ST STE 200
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3639
Practice Address - Country:US
Practice Address - Phone:316-351-8517
Practice Address - Fax:316-260-6494
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2626106H00000X
KS2812106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist