Provider Demographics
NPI:1336206457
Name:SMITH, RANDY J (PHD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NORTH COLLEGE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-5932
Mailing Address - Country:US
Mailing Address - Phone:972-923-1130
Mailing Address - Fax:972-923-1151
Practice Address - Street 1:100 NORTH COLLEGE
Practice Address - Street 2:SUITE 304
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5932
Practice Address - Country:US
Practice Address - Phone:972-923-1130
Practice Address - Fax:972-923-1151
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25104103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist