Provider Demographics
NPI:1144033796
Name:RANDALL, GERALD (CHW)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:RANDALL
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 HARRISON AVE # 40649368
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1929
Mailing Address - Country:US
Mailing Address - Phone:833-427-6739
Mailing Address - Fax:
Practice Address - Street 1:28 HARDING ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02346-1014
Practice Address - Country:US
Practice Address - Phone:321-368-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-28
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACHW5204171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator