Healthcare Provider Details

I. General information

NPI: 1740960665
Provider Name (Legal Business Name): ELISE RANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HARMON PL STE 103
MINNEAPOLIS MN
55403-2045
US

IV. Provider business mailing address

7116 W 113TH ST
MINNEAPOLIS MN
55438-2448
US

V. Phone/Fax

Practice location:
  • Phone: 651-319-6210
  • Fax:
Mailing address:
  • Phone: 612-559-2729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126963
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: