Provider Demographics
NPI:1376078600
Name:RANDLE, KATHLEEN MILLER (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MILLER
Last Name:RANDLE
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 1:919 73RD ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5421
Mailing Address - Country:US
Mailing Address - Phone:262-515-4690
Mailing Address - Fax:
Practice Address - Street 1:3800 N 91ST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-2368
Practice Address - Country:US
Practice Address - Phone:623-772-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP10539235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42690900Medicaid