Provider Demographics
NPI:1609221308
Name:PARKER, RANDALL M (LCSW, CADC)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:M
Last Name:PARKER
Suffix:
Gender:M
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 1ST ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4003
Mailing Address - Country:US
Mailing Address - Phone:208-681-2208
Mailing Address - Fax:
Practice Address - Street 1:495 EMERALD AVE
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3968
Practice Address - Country:US
Practice Address - Phone:208-932-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-01
Last Update Date:2025-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-44631101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty