Provider Demographics
NPI:1609806934
Name:RANDOLPH, DEBORAH KAY (LCSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:KAY
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15401 N. MAY AVENUE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-9079
Mailing Address - Country:US
Mailing Address - Phone:405-509-1384
Mailing Address - Fax:405-563-9416
Practice Address - Street 1:15401 N. MAY AVENUE
Practice Address - Street 2:SUITE 600
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-9079
Practice Address - Country:US
Practice Address - Phone:405-509-1384
Practice Address - Fax:405-563-9416
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK248519001Medicare ID - Type Unspecified
OKS23400Medicare UPIN