Healthcare Provider Details

I. General information

NPI: 1104780378
Provider Name (Legal Business Name): AUTUMN RAIN RANDALL MHC-LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6336 99TH ST
REGO PARK NY
11374-1979
US

IV. Provider business mailing address

6336 99TH ST
REGO PARK NY
11374-1979
US

V. Phone/Fax

Practice location:
  • Phone: 718-459-2558
  • Fax: 718-770-7676
Mailing address:
  • Phone: 718-459-2558
  • Fax: 718-770-7676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP140191
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: