Provider Demographics
NPI:1427610013
Name:CHELOHA, RANDALL SCOTT
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:CHELOHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2598
Mailing Address - Country:US
Mailing Address - Phone:610-755-7879
Mailing Address - Fax:
Practice Address - Street 1:5310 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2598
Practice Address - Country:US
Practice Address - Phone:610-755-7879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7574103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty