Provider Demographics
NPI:1972779239
Name:RANDELIA, KATHLEEN E (MA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:E
Last Name:RANDELIA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:E
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:6484 BORDEN ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47124
Mailing Address - Country:US
Mailing Address - Phone:812-704-4260
Mailing Address - Fax:
Practice Address - Street 1:2627 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2536
Practice Address - Country:US
Practice Address - Phone:812-944-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional