Healthcare Provider Details

I. General information

NPI: 1992061832
Provider Name (Legal Business Name): RANDON KEONI AEA MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5802 RAINIER AVE S
SEATTLE WA
98118-2706
US

IV. Provider business mailing address

17045 HILLSIDE DR NE #A
LAKE FOREST PARK WA
98155-5344
US

V. Phone/Fax

Practice location:
  • Phone: 206-723-1980
  • Fax: 206-721-3930
Mailing address:
  • Phone: 206-817-1771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH00010910
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: