Provider Demographics
NPI:1720548506
Name:RANDOLPH, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11590 CENTURY BLVD STE 116
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3317
Practice Address - Country:US
Practice Address - Phone:513-771-7239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst