Provider Demographics
NPI:1699372359
Name:RANDOLPH, SHANITTA ANTALLESHIA
Entity Type:Individual
Prefix:
First Name:SHANITTA
Middle Name:ANTALLESHIA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 E 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-1832
Mailing Address - Country:US
Mailing Address - Phone:907-310-0769
Mailing Address - Fax:
Practice Address - Street 1:1709 BRAGAW ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3436
Practice Address - Country:US
Practice Address - Phone:907-346-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health