Provider Demographics
NPI:1851858237
Name:RANDOLPH, DEWAYNE
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 TELEGRAPH STATION LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-4006
Mailing Address - Country:US
Mailing Address - Phone:800-648-9845
Mailing Address - Fax:
Practice Address - Street 1:1005 TELEGRAPH STATION LN
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-4006
Practice Address - Country:US
Practice Address - Phone:800-648-9845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
VA0718000340101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral