Provider Demographics
NPI:1013060946
Name:RANDOLPH, PATRICK DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:DAVID
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5147 69TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-1646
Mailing Address - Country:US
Mailing Address - Phone:806-771-8808
Mailing Address - Fax:806-771-8809
Practice Address - Street 1:5147 69TH ST STE D
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1646
Practice Address - Country:US
Practice Address - Phone:806-771-8808
Practice Address - Fax:806-771-8809
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24796103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099265302Medicaid
TX099265302Medicaid