Provider Demographics
NPI:1720484298
Name:DEVINE, RANDI (LMSW)
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:
Last Name:DEVINE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13403 N GOVERNMENT WAY STE 118
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8906
Mailing Address - Country:US
Mailing Address - Phone:208-660-8701
Mailing Address - Fax:
Practice Address - Street 1:13403 N GOVERNMENT WAY STE 118
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8906
Practice Address - Country:US
Practice Address - Phone:208-660-8701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-34282104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1720484298OtherBLUE CROSS