Provider Demographics
NPI:1679585707
Name:MOREDOCK, RANDOLPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:
Last Name:MOREDOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CENTENNIAL AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2328
Mailing Address - Country:US
Mailing Address - Phone:585-637-5001
Mailing Address - Fax:
Practice Address - Street 1:60 CENTENNIAL AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2328
Practice Address - Country:US
Practice Address - Phone:585-637-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18 002810101YM0800X
NY06 000512106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health