MEDICARE: MR. RANDALL LEE SMIDDY MED, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	13445	TX

General Provider Information

NPI Number	:	1154600914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDALL LEE SMIDDY MED, LPC

Provider Business Mailing Address
First Line	:	2330 HAWTHORNE DR
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79109-3412
Country	:	US
Telephone Number	:	806-354-0326
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 S CLEVELAND ST
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79102-4211
Country	:	US
Telephone Number	:	806-677-5450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	08/11/2011

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