Provider Demographics
NPI:1811486442
Name:RANDAK, PAUL STILES
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:STILES
Last Name:RANDAK
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 1:2560 E WOODCHUCK WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-2813
Mailing Address - Country:US
Mailing Address - Phone:801-450-0199
Mailing Address - Fax:
Practice Address - Street 1:850 E 9400 S STE 103
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4104
Practice Address - Country:US
Practice Address - Phone:801-450-0199
Practice Address - Fax:888-503-2513
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT376787-6006101YA0400X
UT376787-3904101YM0800X
UT376787-3902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)