Provider Demographics
NPI:1508183013
Name:RANDOLPH'S PROFESSIONAL TREATMENT SERVICES, PLLC
Entity Type:Organization
Organization Name:RANDOLPH'S PROFESSIONAL TREATMENT SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:BRANNON
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MS, LPC
Authorized Official - Phone:479-725-3813
Mailing Address - Street 1:6801 ISAACS ORCHARD RD
Mailing Address - Street 2:STE. 215
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6545
Mailing Address - Country:US
Mailing Address - Phone:479-725-3813
Mailing Address - Fax:479-419-4046
Practice Address - Street 1:6801 ISAACS ORCHARD RD
Practice Address - Street 2:STE. 215
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6545
Practice Address - Country:US
Practice Address - Phone:479-725-3813
Practice Address - Fax:479-419-4046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0309038101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR181106719Medicaid