Provider Demographics
NPI:1275898520
Name:RANDOLPH, HEATHER ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:ANN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 TREE FROG WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-7523
Mailing Address - Country:US
Mailing Address - Phone:208-608-0906
Mailing Address - Fax:904-417-7021
Practice Address - Street 1:131 TREE FROG WAY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-7523
Practice Address - Country:US
Practice Address - Phone:208-608-0906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21575235Z00000X
NVSP-2256235Z00000X
FLSA20055235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21575OtherCA STATE LICENSE
ID12152811OtherASHA CERTIFICATE OF CLINICAL COMPETENCE
NVSP-2256OtherNV STATE LICENSE