Provider Demographics
NPI:1265413280
Name:RANDOLPH, BEVERLY MICHELLE (PT)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:MICHELLE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:BEVERLY
Other - Middle Name:MICHELLE
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:810 S BROOM ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-4245
Mailing Address - Country:US
Mailing Address - Phone:302-652-1181
Mailing Address - Fax:
Practice Address - Street 1:810 S BROOM ST
Practice Address - Street 2:SUITE B
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-4245
Practice Address - Country:US
Practice Address - Phone:302-652-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001461225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist