Provider Demographics
NPI:1811143092
Name:RANDOLPH, VERONICA LATONYA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:LATONYA
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 VIRIDIAN VILLAGE DR APT 4321
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76005-4562
Mailing Address - Country:US
Mailing Address - Phone:901-737-9008
Mailing Address - Fax:
Practice Address - Street 1:6025 PRIMACY PKWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5763
Practice Address - Country:US
Practice Address - Phone:901-767-1040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120834225X00000X
TN3020225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist