Healthcare Provider Details

I. General information

NPI: 1508135625
Provider Name (Legal Business Name): RANDALL ALAN ANDERSON LPE-I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SKYLINE DR
RUSSELLVILLE AR
72801-3362
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-1298
  • Fax: 479-968-6053
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-750-4843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number88-12EI
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number88-12EI
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: