Provider Demographics
NPI:1932205705
Name:RANDALL, RON DEWAYNE (MED LPC LMFT)
Entity type:Individual
Prefix:MR
First Name:RON
Middle Name:DEWAYNE
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MED LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3404 MARTIN LYDON
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-1419
Mailing Address - Country:US
Mailing Address - Phone:817-927-5462
Mailing Address - Fax:817-920-9553
Practice Address - Street 1:2707 AIRPORT FREEWAY
Practice Address - Street 2:SUITE 213
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-2370
Practice Address - Country:US
Practice Address - Phone:817-920-9779
Practice Address - Fax:817-920-9553
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3617106H00000X
TX5254101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist