Provider Demographics
NPI:1720636129
Name:RANDOLPH, NATASHA MARIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:MARIA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 WEATHERFORD HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-1251
Mailing Address - Country:US
Mailing Address - Phone:682-258-9865
Mailing Address - Fax:
Practice Address - Street 1:2541 WEATHERFORD HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-1251
Practice Address - Country:US
Practice Address - Phone:682-258-9865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113929235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist