Healthcare Provider Details

I. General information

NPI: 1477296630
Provider Name (Legal Business Name): MARIA RANDALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 MAGNOLIA LEAF DR
HERNANDO MS
38632-2497
US

IV. Provider business mailing address

3240 MAGNOLIA LEAF DR
HERNANDO MS
38632-2497
US

V. Phone/Fax

Practice location:
  • Phone: 901-351-4327
  • Fax:
Mailing address:
  • Phone: 901-351-4327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW00000007044
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: