Provider Demographics
NPI:1316908841
Name:DORN, RANDI S (EDD, ABPP)
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:S
Last Name:DORN
Suffix:
Gender:F
Credentials:EDD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 PARK LN
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:MA
Mailing Address - Zip Code:01451-1436
Mailing Address - Country:US
Mailing Address - Phone:978-452-3711
Mailing Address - Fax:978-441-9351
Practice Address - Street 1:77 E MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1251
Practice Address - Country:US
Practice Address - Phone:978-452-3711
Practice Address - Fax:978-441-9351
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1797103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW0152Medicare ID - Type UnspecifiedPSYCHOLOGIST PROVIDER