Provider Demographics
NPI:1295807402
Name:RANDOLPH, CAROL (PHD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 LA JOLLA BLVD STE 523
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7651
Mailing Address - Country:US
Mailing Address - Phone:619-699-8484
Mailing Address - Fax:
Practice Address - Street 1:6130 VISTA DE LA MESA
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-6546
Practice Address - Country:US
Practice Address - Phone:619-699-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15060103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist