Provider Demographics
NPI:1669219515
Name:CALVERT, RANDAL SHANE
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:SHANE
Last Name:CALVERT
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 1:122 NOWELL ST APT K
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-1861
Mailing Address - Country:US
Mailing Address - Phone:678-863-2912
Mailing Address - Fax:
Practice Address - Street 1:1300 CEDAR SHOALS DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-3541
Practice Address - Country:US
Practice Address - Phone:800-849-5502
Practice Address - Fax:770-908-2203
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician