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NPI Code Detail

MEDICARE: HEATHER JEAN RANDOLPH LPC

MEDICARE: HEATHER JEAN RANDOLPH 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
1101YM0800XMental Health Counselor2004032818MO

General Provider Information

NPI Number : 1417098112
Entity Type Code : Individual
Provider Name (Legal Business Name) : HEATHER JEAN RANDOLPH LPC
Provider Business Mailing Address
First Line : 1034 N CEDAR ST
Second Line :
City : NEVADA
State : MO
Zip : 64772-1437
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1500 W ASHLAND ST
Second Line :
City : NEVADA
State : MO
Zip : 64772-1710
Country : US
Telephone Number : 417-667-2666
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/08/2007
Last Update Date : 07/08/2007

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Directions to “ HEATHER JEAN RANDOLPH LPC” Practice Location

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