Provider Demographics
NPI:1043940133
Name:RANDALL, ABBY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 11TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6048
Mailing Address - Country:US
Mailing Address - Phone:701-356-0062
Mailing Address - Fax:701-356-5412
Practice Address - Street 1:3001 11TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6048
Practice Address - Country:US
Practice Address - Phone:701-356-0062
Practice Address - Fax:701-356-5412
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN528446235Z00000X
ND2098235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist