Provider Demographics
NPI:1356525349
Name:OWENS, MATTIE 'RANDI' MAE (MSED, CADC-I, LPC)
Entity type:Individual
Prefix:
First Name:MATTIE 'RANDI'
Middle Name:MAE
Last Name:OWENS
Suffix:
Gender:F
Credentials:MSED, CADC-I, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W SCHEELITE DR
Mailing Address - Street 2:P.O. BOX 871508
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-1304
Mailing Address - Country:US
Mailing Address - Phone:907-373-2175
Mailing Address - Fax:907-373-2175
Practice Address - Street 1:491 N KNIK ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7049
Practice Address - Country:US
Practice Address - Phone:907-376-9500
Practice Address - Fax:907-373-2175
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK0046101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional