Provider Demographics
NPI:1861659302
Name:RANDOLPH, HEATHER W (PSYD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:W
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7511 NEW LAGRANGE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4859
Mailing Address - Country:US
Mailing Address - Phone:502-423-1151
Mailing Address - Fax:502-423-1748
Practice Address - Street 1:7511 NEW LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4859
Practice Address - Country:US
Practice Address - Phone:502-423-1151
Practice Address - Fax:502-423-1748
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1491103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3001424Medicare PIN