MEDICARE: MR. KEVIN AURELIUS RANDALL II B.S.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1629419825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN AURELIUS RANDALL II B.S.

Provider Business Mailing Address
First Line	:	1808 NW 9TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-2420
Country	:	US
Telephone Number	:	405-618-0558
Fax Number	:

Provider Business Practice Location Address
First Line	:	1808 NW 9TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-2420
Country	:	US
Telephone Number	:	405-618-0558
Fax Number	:

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

Provider Enumeration Date	:	07/16/2013
Last Update Date	:	07/16/2013

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