Healthcare Provider Details

I. General information

NPI: 1376736124
Provider Name (Legal Business Name): PHYLLIS RANDLE LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MERCANTILE LN 232
LARGO MD
20774-5341
US

IV. Provider business mailing address

1400 MERCANTILE LN 232
LARGO MD
20774-5341
US

V. Phone/Fax

Practice location:
  • Phone: 301-583-0001
  • Fax: 301-583-3403
Mailing address:
  • Phone: 301-583-0001
  • Fax: 301-583-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09062
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: