Provider Demographics
NPI:1154473080
Name:RANDOLPH, SHERRY LYNNE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:LYNNE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 EDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-2111
Mailing Address - Country:US
Mailing Address - Phone:806-655-7753
Mailing Address - Fax:806-358-4345
Practice Address - Street 1:4211 W INTERSTATE 40
Practice Address - Street 2:STE 203
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-6053
Practice Address - Country:US
Practice Address - Phone:806-374-5950
Practice Address - Fax:806-358-4345
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19478101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84640LOtherBLUE CROSS BLUE SHIELD #