Provider Demographics
NPI:1467832873
Name:RANDOLPH, CARLIN
Entity type:Individual
Prefix:MR
First Name:CARLIN
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-2802
Mailing Address - Country:US
Mailing Address - Phone:917-202-8615
Mailing Address - Fax:
Practice Address - Street 1:762 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-2802
Practice Address - Country:US
Practice Address - Phone:917-202-8615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY613543122103K00000X
NY918394151103K00000X
NY464755101103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst