Provider Demographics
NPI:1386906436
Name:RANDALL, JOHN CARL (LMSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CARL
Last Name:RANDALL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3132 W IRENE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5874
Mailing Address - Country:US
Mailing Address - Phone:315-278-6609
Mailing Address - Fax:
Practice Address - Street 1:2273 S VISTA AVE
Practice Address - Street 2:STE 190
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-7341
Practice Address - Country:US
Practice Address - Phone:208-343-2737
Practice Address - Fax:208-342-3238
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-32190104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker