Provider Demographics
NPI:1922148451
Name:RANDOLPH, IVONNE CARMEN (MACCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:IVONNE
Middle Name:CARMEN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5791 FALLING TREE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-7993
Mailing Address - Country:US
Mailing Address - Phone:407-595-2710
Mailing Address - Fax:
Practice Address - Street 1:5791 FALLING TREE LN
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-7993
Practice Address - Country:US
Practice Address - Phone:407-595-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
FLSA 1206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884535200Medicaid