Provider Demographics
NPI:1336538123
Name:RANDOLPH, LISA (MSC, MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MSC, MFT
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:
Other - Last Name:FENNESSEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSC, MFT
Mailing Address - Street 1:7121 GRAND PRAIRIE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-8763
Mailing Address - Country:US
Mailing Address - Phone:719-229-5597
Mailing Address - Fax:
Practice Address - Street 1:7121 GRAND PRAIRIE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-8763
Practice Address - Country:US
Practice Address - Phone:719-229-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14068106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist