Provider Demographics
NPI:1629217930
Name:RANDOLPH, YVONNE M (MA)
Entity Type:Individual
Prefix:MISS
First Name:YVONNE
Middle Name:M
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8245 WESTPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:TN
Mailing Address - Zip Code:38387
Mailing Address - Country:US
Mailing Address - Phone:731-614-2316
Mailing Address - Fax:731-986-9138
Practice Address - Street 1:8245 WESTPORT ROAD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:TN
Practice Address - Zip Code:38387
Practice Address - Country:US
Practice Address - Phone:731-614-2316
Practice Address - Fax:731-986-9138
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst