Healthcare Provider Details

I. General information

NPI: 1750749321
Provider Name (Legal Business Name): RANDY SONGIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 LAKE JEAN DR
ORLANDO FL
32817-2329
US

IV. Provider business mailing address

3407 LAKE JEAN DR
ORLANDO FL
32817-2329
US

V. Phone/Fax

Practice location:
  • Phone: 407-580-0559
  • Fax:
Mailing address:
  • Phone: 407-580-0559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: