Provider Demographics
NPI:1174891618
Name:MORRIS-OSTROM, RANDALL LEE (PSYD, LP)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:MORRIS-OSTROM
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DECATUR AVE N STE 109
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 DECATUR AVE N STE 109
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4363
Practice Address - Country:US
Practice Address - Phone:763-746-2419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6179103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical