Provider Demographics
NPI:1639536147
Name:RANDOLPH, BRYAN J (LICSW)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:J
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 175
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:NH
Mailing Address - Zip Code:03765-0175
Mailing Address - Country:US
Mailing Address - Phone:603-989-3500
Mailing Address - Fax:
Practice Address - Street 1:2274 MOUNT MOOSILAUKE HWY
Practice Address - Street 2:
Practice Address - City:PIKE
Practice Address - State:NH
Practice Address - Zip Code:03780-5615
Practice Address - Country:US
Practice Address - Phone:603-989-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH18941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical