Basic Information
| Provider Information | |||||||||
| NPI: | 1447413430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALA | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LPC,LCDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8205 LAUREN WAY | ||||||||
| Address2: | |||||||||
| City: | WATAUGA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761481125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145772792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 36000 DARNALL LOOP | ||||||||
| Address2: | |||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765445095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542888025 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 07/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 9213 | TX | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 19458 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.