Provider Demographics
NPI:1720091291
Name:GEARHART, RANDY THOMAS (MSSA, LCSW)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:THOMAS
Last Name:GEARHART
Suffix:
Gender:M
Credentials:MSSA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 W HILLVIEW ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-2421
Mailing Address - Country:US
Mailing Address - Phone:602-432-4965
Mailing Address - Fax:602-900-4545
Practice Address - Street 1:1110 E MISSOURI AVE
Practice Address - Street 2:STE 640
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2735
Practice Address - Country:US
Practice Address - Phone:602-432-4965
Practice Address - Fax:602-900-4545
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-105361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical