Provider Demographics
NPI:1356070643
Name:RANDOLPH, TAVEYUS SHUDON
Entity Type:Individual
Prefix:MR
First Name:TAVEYUS
Middle Name:SHUDON
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 RALPH WOOD RD APT 2
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-1197
Mailing Address - Country:US
Mailing Address - Phone:229-255-0686
Mailing Address - Fax:
Practice Address - Street 1:1826 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3620
Practice Address - Country:US
Practice Address - Phone:800-595-5229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty