Provider Demographics
NPI:1700919099
Name:WALL, RANDY LEE (LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LEE
Last Name:WALL
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 COLD SPRINGS RD E
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-8004
Mailing Address - Country:US
Mailing Address - Phone:704-789-3975
Mailing Address - Fax:
Practice Address - Street 1:2560 COLD SPRINGS RD E
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-8004
Practice Address - Country:US
Practice Address - Phone:704-789-3975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5048101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral