Healthcare Provider Details

I. General information

NPI: 1780916577
Provider Name (Legal Business Name): JEFFREY GORDON RANDALL LCSW/MSSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TOWER DR
SUN PRAIRIE WI
53590-1239
US

IV. Provider business mailing address

10 TOWER DR
SUN PRAIRIE WI
53590-1239
US

V. Phone/Fax

Practice location:
  • Phone: 608-825-3500
  • Fax: 608-824-4918
Mailing address:
  • Phone: 608-825-3500
  • Fax: 608-824-4918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8455-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: