Provider Demographics
NPI:1073619813
Name:RANDOLPH, REBECCA JANE (MPT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JANE
Other - Last Name:ODELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:3910 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9756
Mailing Address - Country:US
Mailing Address - Phone:304-757-7293
Mailing Address - Fax:304-757-0574
Practice Address - Street 1:3910 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9756
Practice Address - Country:US
Practice Address - Phone:304-757-7293
Practice Address - Fax:304-757-0574
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006514Medicaid
O'4193391Medicare PIN