Provider Demographics
NPI:1245726181
Name:RANDOLPH, AMANDA MARIE (SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 AVIGNON DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5120
Mailing Address - Country:US
Mailing Address - Phone:601-605-6777
Mailing Address - Fax:
Practice Address - Street 1:81 WINDSOR BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-3143
Practice Address - Country:US
Practice Address - Phone:662-329-0050
Practice Address - Fax:601-607-1358
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4447235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist