Healthcare Provider Details

I. General information

NPI: 1073949970
Provider Name (Legal Business Name): CARLY ELIZABETH RANDO NP-PSYCHIATRIC - MEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 PEARL ST
BROCKTON MA
02301-2825
US

IV. Provider business mailing address

529 PEARL ST
BROCKTON MA
02301-2825
US

V. Phone/Fax

Practice location:
  • Phone: 508-580-2211
  • Fax: 508-427-1772
Mailing address:
  • Phone: 508-580-2211
  • Fax: 508-427-1772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2288512
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2288512
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2288512
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: