Provider Demographics
NPI:1154600914
Name:SMIDDY, RANDALL LEE (MED, LPC)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:LEE
Last Name:SMIDDY
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:SMIDDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2330 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-3412
Mailing Address - Country:US
Mailing Address - Phone:806-354-0326
Mailing Address - Fax:
Practice Address - Street 1:1601 S CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79102-4211
Practice Address - Country:US
Practice Address - Phone:806-677-5450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13445101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional