Provider Demographics
NPI:1194034835
Name:RANDOLPH, LEAH SUSAN (LADC I, MM)
Entity Type:Individual
Prefix:MS
First Name:LEAH
Middle Name:SUSAN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LADC I, MM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WAUMBECK ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-1220
Mailing Address - Country:US
Mailing Address - Phone:617-291-3623
Mailing Address - Fax:
Practice Address - Street 1:21 WAUMBECK ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-1220
Practice Address - Country:US
Practice Address - Phone:617-291-3623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)