Provider Demographics
NPI:1457371189
Name:RANDALL, MARQUE E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARQUE
Middle Name:E
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 200 E
Mailing Address - Street 2:STE 114-A
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2398
Mailing Address - Country:US
Mailing Address - Phone:435-753-2687
Mailing Address - Fax:
Practice Address - Street 1:1300 N 200 E
Practice Address - Street 2:STE 114-A
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2398
Practice Address - Country:US
Practice Address - Phone:435-753-2687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT52285242501103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT85006OtherPEHP
UT107019240103OtherIHC
UT885077OtherDMBA
UT52285242501001OtherBCBS