Provider Demographics
NPI:1366059479
Name:RANDALL, EDIE
Entity type:Individual
Prefix:
First Name:EDIE
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19602-2049
Mailing Address - Country:US
Mailing Address - Phone:610-507-6419
Mailing Address - Fax:
Practice Address - Street 1:900 HERITAGE DR STE 910
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-9223
Practice Address - Country:US
Practice Address - Phone:484-458-5138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPCO12565101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional