Provider Demographics
NPI:1700881463
Name:RANDOLPH, JOHN JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JAMES
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W PARK ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1378
Mailing Address - Country:US
Mailing Address - Phone:603-653-0330
Mailing Address - Fax:603-653-0330
Practice Address - Street 1:20 W PARK ST
Practice Address - Street 2:STE 215
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1378
Practice Address - Country:US
Practice Address - Phone:603-448-6779
Practice Address - Fax:603-653-0246
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1027103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00068596OtherBLUE CROSS BLUE SHIELD
NH06Y007347NH01OtherANTHEM BLUE CROSS BLUE SH
VT00068596OtherBLUE CROSS BLUE SHIELD
NH06Y007347NH01OtherANTHEM BLUE CROSS BLUE SH