Provider Demographics
NPI:1629301874
Name:RANDOLPH, KAREN ANN (CMT, ED D)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CMT, ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 MILTON DR
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-3024
Mailing Address - Country:US
Mailing Address - Phone:510-275-3895
Mailing Address - Fax:
Practice Address - Street 1:5 BON AIR RD STE C-116
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1143
Practice Address - Country:US
Practice Address - Phone:510-417-5773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA703556173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225700000XOtherMASSAGE THERAPIST