Healthcare Provider Details

I. General information

NPI: 1437700721
Provider Name (Legal Business Name): JAYME T RANDLE SR. CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 NAVE RD SE
MASSILLON OH
44646-9604
US

IV. Provider business mailing address

625 CLEVELAND AVE NW
CANTON OH
44702-1805
US

V. Phone/Fax

Practice location:
  • Phone: 330-837-9411
  • Fax: 330-837-4603
Mailing address:
  • Phone: 330-455-0374
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.177447
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: