Provider Demographics
NPI:1932362696
Name:RANDALL, KATHLEEN (LISW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 SYLVAN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-1550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2999 SUNSET BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3496
Practice Address - Country:US
Practice Address - Phone:803-939-9699
Practice Address - Fax:803-939-9086
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC66121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical