Provider Demographics
NPI:1528185881
Name:RANDOLPH, AMANDA (SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 BROCKTON DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-8749
Mailing Address - Country:US
Mailing Address - Phone:304-288-7830
Mailing Address - Fax:
Practice Address - Street 1:1539 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1306
Practice Address - Country:US
Practice Address - Phone:304-363-8479
Practice Address - Fax:304-366-9125
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12053347235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist