1306930425 NPI number — DR. TANYA MICHELLE RANDOLPH-ELGIN PSY.D.

Table of content: DR. TANYA MICHELLE RANDOLPH-ELGIN PSY.D. (NPI 1306930425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306930425 NPI number — DR. TANYA MICHELLE RANDOLPH-ELGIN PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDOLPH-ELGIN
Provider First Name:
TANYA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

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:
1306930425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STROMSBURG
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68666-3015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-764-8183
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 E 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STROMSBURG
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68666-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-764-2491
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  510 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 559-692 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 241839 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 08468 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 6866600 . This is a "TRIWEST" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".