Provider Demographics
NPI:1811634207
Name:RANDALL, DAMIAN WILLIAM (ADT)
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:WILLIAM
Last Name:RANDALL
Suffix:
Gender:M
Credentials:ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 LASALLE RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286
Mailing Address - Country:US
Mailing Address - Phone:410-773-0500
Mailing Address - Fax:410-773-0501
Practice Address - Street 1:8600 LASALLE RD
Practice Address - Street 2:212
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286
Practice Address - Country:US
Practice Address - Phone:866-929-1754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT2649101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)