Healthcare Provider Details

I. General information

NPI: 1457371189
Provider Name (Legal Business Name): MARQUE E RANDALL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 200 E STE 114-A
LOGAN UT
84341-2398
US

IV. Provider business mailing address

1300 N 200 E STE 114-A
LOGAN UT
84341-2398
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-2687
  • Fax:
Mailing address:
  • Phone: 435-753-2687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number52285242501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: