Provider Demographics
NPI:1740904226
Name:KLAIRE-JEFFERSON, RANDI L (MA, ATR)
Entity type:Individual
Prefix:MS
First Name:RANDI
Middle Name:L
Last Name:KLAIRE-JEFFERSON
Suffix:
Gender:F
Credentials:MA, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 SW DAUPHIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5854
Mailing Address - Country:US
Mailing Address - Phone:423-341-3356
Mailing Address - Fax:
Practice Address - Street 1:537 SW DAUPHIN AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5854
Practice Address - Country:US
Practice Address - Phone:423-341-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86-069221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK462-732-55-629-0OtherDRIVERS LICENSE