Healthcare Provider Details

I. General information

NPI: 1609361385
Provider Name (Legal Business Name): RANDAL RATZLAFF LCDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 SPUR 156
WASKOM TX
75692-9129
US

IV. Provider business mailing address

670 SPUR 156
WASKOM TX
75692-9129
US

V. Phone/Fax

Practice location:
  • Phone: 903-687-2586
  • Fax:
Mailing address:
  • Phone: 903-687-2586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12963
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: