Provider Demographics
NPI:1295354686
Name:RANDOLPH, HOLLY (OTD)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 PEPPER AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2704
Mailing Address - Country:US
Mailing Address - Phone:804-477-4908
Mailing Address - Fax:
Practice Address - Street 1:721 PEPPER AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2704
Practice Address - Country:US
Practice Address - Phone:804-477-4908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2021-12-03
Deactivation Date:2021-10-26
Deactivation Code:
Reactivation Date:2021-12-03
Provider Licenses
StateLicense IDTaxonomies
VA0119005003225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist