Provider Demographics
NPI:1477345288
Name:RANDOLPH, CLINTON (LMT)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 DEVONSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-1327
Mailing Address - Country:US
Mailing Address - Phone:309-415-0275
Mailing Address - Fax:309-415-0275
Practice Address - Street 1:1409 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-6157
Practice Address - Country:US
Practice Address - Phone:309-415-0275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.022994225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist