Provider Demographics
NPI:1376678342
Name:RANDOLPH, ALICIA ANN (PT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:201 16TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5226
Practice Address - Country:US
Practice Address - Phone:206-326-3000
Practice Address - Fax:206-326-2785
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003418225100000X, 2251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0221473OtherWASHINGTON L&I
WA8407082Medicaid
WAP00802476OtherRR MEDICARE
WA1376678342Medicaid
WA8407082Medicaid