1306124961 NPI number — DEBORAH RANDOLPH, LCSW, PC

Table of content: (NPI 1306124961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306124961 NPI number — DEBORAH RANDOLPH, LCSW, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEBORAH RANDOLPH, LCSW, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306124961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1441 NW 150TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73013-1305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-509-1384
Provider Business Mailing Address Fax Number:
405-563-9416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1441 NW 150TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73013-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-509-1384
Provider Business Practice Location Address Fax Number:
405-563-9416
Provider Enumeration Date:
08/01/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RANDOLPH
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
405-509-1384

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1766 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)