Healthcare Provider Details

I. General information

NPI: 1447193701
Provider Name (Legal Business Name): JULIA RANDLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 FULTON ST E STE 102
ADA MI
49301-8454
US

IV. Provider business mailing address

1600 ARDMORE ALCOA WAY APT 301
LOUISVILLE TN
37777-3092
US

V. Phone/Fax

Practice location:
  • Phone: 616-425-7701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6352001051
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: