Healthcare Provider Details

I. General information

NPI: 1659550879
Provider Name (Legal Business Name): RANDALL RAY MASTERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S KITCHELL AVE
OLNEY IL
62450-1500
US

IV. Provider business mailing address

302 S KITCHELL AVE
OLNEY IL
62450-1500
US

V. Phone/Fax

Practice location:
  • Phone: 618-392-2725
  • Fax:
Mailing address:
  • Phone: 618-392-2725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.006994
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number969847
License Number StateIL

VIII. Authorized Official

Name: RANDALL R MASTERSON
Title or Position: ASSOCIATE
Credential: M.S.C.S.P.
Phone: 618-392-2725