Provider Demographics
NPI:1477977346
Name:MORMAN, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:MORMAN
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 1:804 N. UBER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130
Mailing Address - Country:US
Mailing Address - Phone:215-599-2845
Mailing Address - Fax:215-599-1043
Practice Address - Street 1:2514 N. BROAD STREET
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132
Practice Address - Country:US
Practice Address - Phone:215-599-2845
Practice Address - Fax:215-599-1043
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health