Healthcare Provider Details

I. General information

NPI: 1013434273
Provider Name (Legal Business Name): SHANDY LYNN RANDALL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 RIO GRANDE BLVD NW
ALBUQUERQUE NM
87104-2529
US

IV. Provider business mailing address

224 CAMINO DOS SW
ALBUQUERQUE NM
87105
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-2695
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-10227
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: