Provider Demographics
NPI:1942345632
Name:RANDOLPH, PATRICIA (MA, PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-2918
Mailing Address - Country:US
Mailing Address - Phone:626-482-4021
Mailing Address - Fax:951-898-9858
Practice Address - Street 1:2900 ADAMS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-4335
Practice Address - Country:US
Practice Address - Phone:951-205-5883
Practice Address - Fax:951-898-9858
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25109101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health