Provider Demographics
NPI:1174117543
Name:RANDALL, KAYLEN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KAYLEN
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 1:6901A N 9TH AVE # 525
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6638
Mailing Address - Country:US
Mailing Address - Phone:334-226-2604
Mailing Address - Fax:
Practice Address - Street 1:105 E GREGORY SQ
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-4971
Practice Address - Country:US
Practice Address - Phone:334-226-2604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14709235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist