Provider Demographics
NPI:1336824267
Name:THOMPSON, RANDY DALE
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DALE
Last Name:THOMPSON
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 1:4516 S 700 E STE 160
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8327
Mailing Address - Country:US
Mailing Address - Phone:801-699-7690
Mailing Address - Fax:
Practice Address - Street 1:4516 S 700 E STE 160
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8327
Practice Address - Country:US
Practice Address - Phone:801-699-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT284606-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty