Healthcare Provider Details

I. General information

NPI: 1992114417
Provider Name (Legal Business Name): CAMILLE RANDALL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 MACKLIND AVE
SAINT LOUIS MO
63110-1440
US

IV. Provider business mailing address

1129 MACKLIND AVE
SAINT LOUIS MO
63110-1440
US

V. Phone/Fax

Practice location:
  • Phone: 314-534-0200
  • Fax: 314-534-7996
Mailing address:
  • Phone: 314-534-0200
  • Fax: 314-534-7996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071007584
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: