Provider Demographics
NPI:1740267285
Name:PATRICK D RANDOLPH PHD INC
Entity type:Organization
Organization Name:PATRICK D RANDOLPH PHD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STIMAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-771-8808
Mailing Address - Street 1:5147 69TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-1646
Mailing Address - Country:US
Mailing Address - Phone:806-771-8808
Mailing Address - Fax:806-771-8809
Practice Address - Street 1:5147 69TH ST STE D
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1646
Practice Address - Country:US
Practice Address - Phone:806-771-8808
Practice Address - Fax:806-771-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24796103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0095MQOtherBLUE CROSS BLUE SHIELD
TX0992653Medicaid
NM95074732Medicaid