Healthcare Provider Details

I. General information

NPI: 1316908841
Provider Name (Legal Business Name): RANDI S DORN ED.D., ABPP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 E MERRIMACK ST
LOWELL MA
01852-1251
US

IV. Provider business mailing address

72 PARK LN
HARVARD MA
01451-1436
US

V. Phone/Fax

Practice location:
  • Phone: 978-452-3711
  • Fax: 978-441-9351
Mailing address:
  • Phone: 978-452-3711
  • Fax: 978-441-9351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1797
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: