Individual
ETHAN RANDALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
308 E DOWNING ST, TAHLEQUAH, OK 74464-3014
(918) 931-3995
Mailing address
6947 N 460 RD, HULBERT, OK 74441-3250
(918) 931-3995
(918) 931-3994
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
8189
OK
Other
Enumeration date
12/29/2021
Last updated
06/24/2024
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