Provider Demographics
NPI:1215448188
Name:QUEEN, RANDAL ISAAC (EDS)
Entity type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:ISAAC
Last Name:QUEEN
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 COVE RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2403
Mailing Address - Country:US
Mailing Address - Phone:540-562-3900
Mailing Address - Fax:
Practice Address - Street 1:5901 COVE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-2403
Practice Address - Country:US
Practice Address - Phone:540-562-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000201103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool