Provider Demographics
NPI:1245570027
Name:RANDOLPH, THEODORA LUGENE
Entity Type:Individual
Prefix:MS
First Name:THEODORA
Middle Name:LUGENE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THEODORA
Other - Middle Name:LUGENE
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LCPC INTERN
Mailing Address - Street 1:2101 W WARM SPRINGS RD APT 3916
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-5520
Mailing Address - Country:US
Mailing Address - Phone:702-544-9454
Mailing Address - Fax:
Practice Address - Street 1:3514 E TROPICANA AVE STE 2C
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7351
Practice Address - Country:US
Practice Address - Phone:029-923-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5305101YP2500X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional