Provider Demographics
NPI:1497865885
Name:RANDOLPH, ALICE H (EDD MSCP)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:H
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:EDD MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SE CATAWBA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-2666
Mailing Address - Country:US
Mailing Address - Phone:216-215-8000
Mailing Address - Fax:877-734-2032
Practice Address - Street 1:3872 E HARBOR LIGHT LANDING DR
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-3877
Practice Address - Country:US
Practice Address - Phone:216-215-8000
Practice Address - Fax:877-734-2032
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2974103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000137850OtherANTHEM
OH0473590Medicaid
OH294762000OtherMAGELLAN
OHP00127008OtherRAILROAD MEDICARE
OH294762000OtherMAGELLAN