Provider Demographics
NPI:1720641350
Name:COKER, RANDI T (MSP CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:T
Last Name:COKER
Suffix:
Gender:F
Credentials:MSP 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:PO BOX 168
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-0168
Mailing Address - Country:US
Mailing Address - Phone:850-588-9641
Mailing Address - Fax:
Practice Address - Street 1:4015 2ND AVE STE B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-7882
Practice Address - Country:US
Practice Address - Phone:850-588-9641
Practice Address - Fax:888-711-0441
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5412235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist