Healthcare Provider Details

I. General information

NPI: 1811134190
Provider Name (Legal Business Name): CHAD R RANDALL M.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 PROSPECT AVE STE T
KIRKWOOD MO
63122-6024
US

IV. Provider business mailing address

140 PROSPECT AVE STE T
KIRKWOOD MO
63122-6024
US

V. Phone/Fax

Practice location:
  • Phone: 314-200-4482
  • Fax:
Mailing address:
  • Phone: 314-200-4482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2009038524
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: