Provider Demographics
NPI:1912882606
Name:RANDLE, MARIAH SHANTEL
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:SHANTEL
Last Name:RANDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 LAUREL OAK DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2253
Mailing Address - Country:US
Mailing Address - Phone:810-333-5113
Mailing Address - Fax:
Practice Address - Street 1:1040 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-5516
Practice Address - Country:US
Practice Address - Phone:810-424-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI685111567104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker