Provider Demographics
NPI:1689454084
Name:RANDOLPH, MARK HAMPTON (CSAC, CSIT, LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HAMPTON
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:CSAC, CSIT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 STAGELINE RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-1793
Mailing Address - Country:US
Mailing Address - Phone:715-531-6210
Mailing Address - Fax:715-531-6766
Practice Address - Street 1:405 STAGELINE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-1793
Practice Address - Country:US
Practice Address - Phone:715-531-6210
Practice Address - Fax:715-531-6755
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16008-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)