1164518379 NPI number — MS. RANDI LEE ANDERSON JD, LCSW-R

Table of content: MS. RANDI LEE ANDERSON JD, LCSW-R (NPI 1164518379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164518379 NPI number — MS. RANDI LEE ANDERSON JD, LCSW-R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
RANDI
Provider Middle Name:
LEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
JD, LCSW-R
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:
1164518379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E 74TH ST
Provider Second Line Business Mailing Address:
5C
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10021-3712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-232-9633
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1397 2ND AVE
Provider Second Line Business Practice Location Address:
#123
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10021-4505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-232-9633
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2006

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:  069225-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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