Provider Demographics
NPI:1205169000
Name:RANDOLPH, ERICA (LPCC)
Entity type:Individual
Prefix:MS
First Name:ERICA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88062-0933
Mailing Address - Country:US
Mailing Address - Phone:505-919-9572
Mailing Address - Fax:
Practice Address - Street 1:121 TRUCK BYPASS RD
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-9202
Practice Address - Country:US
Practice Address - Phone:505-919-9572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0155861101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional