Provider Demographics
NPI:1598743502
Name:DOW, RANDAL THERON JR (LCSW)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:THERON
Last Name:DOW
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:RANDAL
Other - Middle Name:T
Other - Last Name:DOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3809 W 6200 S
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-3725
Mailing Address - Country:US
Mailing Address - Phone:801-963-4215
Mailing Address - Fax:801-963-4299
Practice Address - Street 1:3809 W 6200 S
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-3725
Practice Address - Country:US
Practice Address - Phone:801-963-4215
Practice Address - Fax:801-963-4299
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8813460535011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT13460535000001OtherBLUE CROSS
UT107001374101OtherINTERMOUNTAIN HEALTH CARE
UT261880OtherDESERET MUTUAL
UT13460535000001OtherBLUE CROSS