Healthcare Provider Details

I. General information

NPI: 1548625007
Provider Name (Legal Business Name): RANDOLPH G. RUSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8461 LAKE WORTH RD SUITE 120
LAKE WORTH FL
33467-2474
US

IV. Provider business mailing address

8461 LAKE WORTH RD SUITE 120
LAKE WORTH FL
33467
US

V. Phone/Fax

Practice location:
  • Phone: 561-201-7180
  • Fax:
Mailing address:
  • Phone: 561-201-7180
  • Fax: 561-839-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDOLPH GRAHAM RUSS
Title or Position: PRESIDENT
Credential:
Phone: 561-201-7180