Provider Demographics
NPI:1568568509
Name:RANDOLPH, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-2177
Mailing Address - Country:US
Mailing Address - Phone:304-269-3923
Mailing Address - Fax:304-269-9733
Practice Address - Street 1:5 BROWN AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-2177
Practice Address - Country:US
Practice Address - Phone:304-269-3923
Practice Address - Fax:304-269-9733
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV454101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV236407OtherMHN
WV383056OtherMAMSI
WVY502969OtherHEALTH PLAN
WV4318099OtherAETNA