Healthcare Provider Details

I. General information

NPI: 1023487576
Provider Name (Legal Business Name): RANDI PARKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RANDI SELLEK

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 11/05/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27TH SPECIAL OPERATIONS MEDICAL GROUP 224 W D. L. INGRAM AVENUE, BLDG. 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

232 WILMINGTON CIR
CLOVIS NM
88101-9395
US

V. Phone/Fax

Practice location:
  • Phone: 815-644-0202
  • Fax:
Mailing address:
  • Phone: 815-644-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.015731
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: