Provider Demographics
NPI:1396976783
Name:RANDALL, WENDY REED (LCAS)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:REED
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6029 CLAPTON DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4263
Mailing Address - Country:US
Mailing Address - Phone:262-960-4739
Mailing Address - Fax:
Practice Address - Street 1:6029 CLAPTON DR
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4263
Practice Address - Country:US
Practice Address - Phone:262-960-4739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1492101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)