1073641510 NPI number — MS. RANDI JO KORELL MS LCPC

Table of content: MS. RANDI JO KORELL MS LCPC (NPI 1073641510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073641510 NPI number — MS. RANDI JO KORELL MS LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORELL
Provider First Name:
RANDI
Provider Middle Name:
JO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WENICK
Provider Other First Name:
RANDI
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1073641510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2445 W HWY 52
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EMMETT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-365-5393
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 N COMMERCIAL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMMETT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-398-8473
Provider Business Practice Location Address Fax Number:
208-398-8311
Provider Enumeration Date:
02/28/2007

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: 101YP2500X , with the licence number:  359 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010152108 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: Q7486 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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