Healthcare Provider Details

I. General information

NPI: 1376736652
Provider Name (Legal Business Name): BEVERLY J RANDALL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N SAINT ASAPH ST
ALEXANDRIA VA
22314-1912
US

IV. Provider business mailing address

1509 19TH ST SE APT #402
WASHINGTON DC
20020-6849
US

V. Phone/Fax

Practice location:
  • Phone: 703-838-4455
  • Fax: 703-838-5070
Mailing address:
  • Phone: 703-838-4455
  • Fax: 703-838-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004187
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: