Provider Demographics
NPI:1437425295
Name:RANDOLPH, BROOKE (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HERITAGE WALK STE 101
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6450
Mailing Address - Country:US
Mailing Address - Phone:770-591-5852
Mailing Address - Fax:770-591-5957
Practice Address - Street 1:301 HERITAGE WALK STE 101
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6450
Practice Address - Country:US
Practice Address - Phone:770-591-5852
Practice Address - Fax:770-591-5957
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007746235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist