Provider Demographics
NPI:1649643339
Name:MACKINTOSH, RANDI
Entity type:Individual
Prefix:DR
First Name:RANDI
Middle Name:
Last Name:MACKINTOSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N MERIDIAN RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-5257
Mailing Address - Country:US
Mailing Address - Phone:850-296-7616
Mailing Address - Fax:
Practice Address - Street 1:1801 N MERIDIAN RD
Practice Address - Street 2:SUITE C
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-5257
Practice Address - Country:US
Practice Address - Phone:850-296-7616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8579103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical