=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497803027
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDOLPH LEE HART MSW, LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 03/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 CLUB RD STE 120
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97401-2439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-393-5983
-----------------------------------------------------
Fax | 541-393-5984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 CLUB RD STE 120
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97401-2439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-393-5983
-----------------------------------------------------
Fax | 541-393-5984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6277
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 02R07
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 210831
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | 500663524
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 210831
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | 500663524
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
Identifier #3
-----------------------------------------------------
Identifier Code | 931269087
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer | EIN
-----------------------------------------------------