Provider Demographics
NPI:1174206098
Name:RANDLE, DEASIAH MASHAWN
Entity type:Individual
Prefix:
First Name:DEASIAH
Middle Name:MASHAWN
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 1:4625 NICOLS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2307
Mailing Address - Country:US
Mailing Address - Phone:952-456-1639
Mailing Address - Fax:
Practice Address - Street 1:4625 NICOLS RD STE 104
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2307
Practice Address - Country:US
Practice Address - Phone:952-456-1639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician