Provider Demographics
NPI:1558448472
Name:RANDOLPH, ANNE MELISSA (RPT)
Entity Type:Individual
Prefix:MS
First Name:ANNE
Middle Name:MELISSA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4091 CORALEE LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3311
Mailing Address - Country:US
Mailing Address - Phone:925-283-1927
Mailing Address - Fax:925-283-1926
Practice Address - Street 1:4091 CORALEE LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3311
Practice Address - Country:US
Practice Address - Phone:925-283-1927
Practice Address - Fax:925-283-1926
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-3346779OtherTAX IDENTIFICATION NUMBER
CA00PT90020Medicare ID - Type UnspecifiedPHYSICAL THERAPIST