Provider Demographics
NPI:1548781511
Name:AUSTIN, RANDOLPH IRVIN JR
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:IRVIN
Last Name:AUSTIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 980
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-0980
Mailing Address - Country:US
Mailing Address - Phone:410-535-3079
Mailing Address - Fax:410-535-2220
Practice Address - Street 1:3819 HARBOR RD UNIT 103
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE BEACH
Practice Address - State:MD
Practice Address - Zip Code:20732-3110
Practice Address - Country:US
Practice Address - Phone:410-286-0547
Practice Address - Fax:410-286-8950
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)