Provider Demographics
NPI:1962809889
Name:MINTEER, RANDALL BRUCE (LCSW-C)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:BRUCE
Last Name:MINTEER
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LOG CANOE CIR STE F
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21666-2106
Mailing Address - Country:US
Mailing Address - Phone:443-775-0126
Mailing Address - Fax:
Practice Address - Street 1:101 LOG CANOE CIR STE F
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21666-2106
Practice Address - Country:US
Practice Address - Phone:443-775-0126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20221104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609550002Medicaid
MDR968OtherCAREFIRST BCBS OF MARYLAND
MD522156095OtherCOMMERCIAL
MD259147-000OtherMAGELLAN BEHAVIORAL HEALTH
MD346646OtherMHN/TRICARE
MD7840093OtherAETNA
MD609550002Medicaid