Provider Demographics
NPI:1265081376
Name:BAILEY, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3875 CIRCLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BCH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-1183
Mailing Address - Country:US
Mailing Address - Phone:954-554-6604
Mailing Address - Fax:
Practice Address - Street 1:1080 NW 15TH ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1331
Practice Address - Country:US
Practice Address - Phone:561-612-4791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8300225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty