Basic Information
| Provider Information | |||||||||
| NPI: | 1720325392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEEKS | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LCDCIII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 446 MORGAN ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452062348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 MORGAN ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138347063 | ||||||||
| FaxNumber: | 5138731567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2013 | ||||||||
| LastUpdateDate: | 06/08/2018 | ||||||||
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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 | LICDC.161585 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | F.1700005 | OH | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0214214 | 05 | OH | MEDICAID |