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General NPI Number Information
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NPI Number | 1881208650
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Entity Type | Individual
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Provider Name | PROF. TRACIE MARIE RANDALL
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Gender | Female
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Dates
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Enumeration Date | 08/31/2020
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Last Update Date | 10/13/2023
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Provider Practice Location Address
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Address Line | 865 WOODSTOCK ROAD
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464
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Country | US
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Telephone | 757-348-2189
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Fax |
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Provider Business Mailing Address
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Address Line | 2085 LYNNHAVEN PKWY STE 106
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City | VIRGINIA BEACH
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State | VA
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Zip | 23456-1497
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Country | US
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Telephone | 757-348-2189
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0701012934
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License Number State | VA
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