Provider Demographics
NPI:1770722829
Name:RALSTON, RANDALL (MS)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:RALSTON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 116TH AVE NE STE 131
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3063
Mailing Address - Country:US
Mailing Address - Phone:425-455-0828
Mailing Address - Fax:425-455-1233
Practice Address - Street 1:1611 116TH AVE NE STE 131
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3063
Practice Address - Country:US
Practice Address - Phone:425-455-0828
Practice Address - Fax:425-455-1233
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 00004607101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health