Provider Demographics
NPI:1912552506
Name:RANDOLPH, HALEY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:LYNN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1883 S US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-9424
Practice Address - Country:US
Practice Address - Phone:765-225-2210
Practice Address - Fax:765-225-2264
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013430A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist