Provider Demographics
NPI:1225252612
Name:RANDOLPH, BENJAMIN D (CADCIII)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:D
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 SE MCLOUGHLIN BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7428
Mailing Address - Country:US
Mailing Address - Phone:503-901-1836
Mailing Address - Fax:503-654-1852
Practice Address - Street 1:10600 SE MCLOUGHLIN BLVD STE 207
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7428
Practice Address - Country:US
Practice Address - Phone:503-901-1836
Practice Address - Fax:503-654-1852
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06-07-75U101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)