Basic Information
| Provider Information | |||||||||
| NPI: | 1528224961 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDELL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | FRANCES | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504754500 | ||||||||
| FaxNumber: | 8504754781 | ||||||||
| Practice Location | |||||||||
| Address1: | 3754 HIGHWAY 90 | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325711096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504165215 | ||||||||
| FaxNumber: | 8504165219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 08/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT11261 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.