Basic Information
| Provider Information | |||||||||
| NPI: | 1023221744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDLE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7045 CAMDEN CT | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631301914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145311770 | ||||||||
| FaxNumber: | 3143816796 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 N NEWSTEAD AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631152534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145311770 | ||||||||
| FaxNumber: | 3143816796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 002207 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | NO.002207 | 01 | MO | CLINICAL SOCIAL WORKER | OTHER |