1881002368 NPI number — EMILY A RANDALL LCSW

Table of content: EMILY A RANDALL LCSW (NPI 1881002368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881002368 NPI number — EMILY A RANDALL LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
EMILY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881002368
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 OLD NEW MILFORD ROAD
Provider Second Line Business Mailing Address:
SUITE 1-B
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-775-2583
Provider Business Mailing Address Fax Number:
203-775-2863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06702-2310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-574-9000
Provider Business Practice Location Address Fax Number:
203-574-9006
Provider Enumeration Date:
07/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  2218 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060669107 . This is a "HEALTHYCT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-CONNECTICARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 13671806 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060669107 . This is a "ANTHEM BEHAVIORRAL HEALTH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "OPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NOT ELIGIBLE . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH-OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "AETNA BEHAVIORAL HEALTH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NOT ELIGIBLE . This is a "MHN TRICARE NORTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: NOT ELIGIBLE . This is a "MHN-MANAGED HEALTH NETWORK" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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