Provider Demographics
NPI:1326878745
Name:REALSON, RANDI (LCSW)
Entity type:Individual
Prefix:MS
First Name:RANDI
Middle Name:
Last Name:REALSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 W. WAUKENA AVENUE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572
Mailing Address - Country:US
Mailing Address - Phone:516-487-3981
Mailing Address - Fax:
Practice Address - Street 1:191 W. WAUKENA AVENUE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572
Practice Address - Country:US
Practice Address - Phone:516-487-3981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0357401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical