Basic Information
| Provider Information | |||||||||
| NPI: | 1023295417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALDRICH | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | LCSW, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707985179 | ||||||||
| FaxNumber: | 2707986075 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | EBH3 | ||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707985179 | ||||||||
| FaxNumber: | 2707986075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2008 | ||||||||
| LastUpdateDate: | 07/30/2018 | ||||||||
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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 | 101YA0400X | 1957 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | C005939 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.