Basic Information
| Provider Information | |||||||||
| NPI: | 1275519795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDAL | ||||||||
| FirstName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6465 WAYZATA BLVD | ||||||||
| Address2: | ST E 315 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529936450 | ||||||||
| FaxNumber: | 9529930300 | ||||||||
| Practice Location | |||||||||
| Address1: | PARK NICOLLET CLINIC IDC | ||||||||
| Address2: | 3800 PARK NICOLLET BLVD | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529933393 | ||||||||
| FaxNumber: | 9529931302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP2548 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.