Provider Demographics
NPI:1316523749
Name:RANDALL, MANDY (LPC, LCDC)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:MARIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18018 OVERLOOK LOOP
Mailing Address - Street 2:SUITE 105, PMB 1029
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259
Mailing Address - Country:US
Mailing Address - Phone:210-595-9158
Mailing Address - Fax:844-832-4701
Practice Address - Street 1:18018 OVERLOOK LOOP
Practice Address - Street 2:SUITE 105, PMB 1029
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-1883
Practice Address - Country:US
Practice Address - Phone:210-595-9158
Practice Address - Fax:844-832-4701
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15052101YA0400X
TX79060101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor