Provider Demographics
NPI:1184819781
Name:RANDOLPH, CURTIS GLEN (LPC)
Entity Type:Individual
Prefix:MR
First Name:CURTIS
Middle Name:GLEN
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2187 N VICKEY ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-6106
Mailing Address - Country:US
Mailing Address - Phone:928-714-6449
Mailing Address - Fax:
Practice Address - Street 1:2187 N VICKEY ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-6106
Practice Address - Country:US
Practice Address - Phone:928-714-6449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-2058101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional