Individual
ALLIE MARIE RANDALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
912 NE KELLY AVE # 100C, GRESHAM, OR 97030-5629
(503) 912-5502
Mailing address
3500 NE 17TH ST APT A107, GRESHAM, OR 97030-4567
(503) 933-1855
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
ABAIN10211664
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
UC0000L4V
—
OR
Enumeration date
01/09/2021
Last updated
01/09/2021
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