Provider Demographics
NPI:1255986998
Name:SMITH, RANDY (LADC)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11990 JONQUIL ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-1797
Mailing Address - Country:US
Mailing Address - Phone:763-478-1418
Mailing Address - Fax:
Practice Address - Street 1:2314 PLYMOUTH AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3636
Practice Address - Country:US
Practice Address - Phone:763-478-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302210101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)