Provider Demographics
NPI:1811463797
Name:RANDOLPH, CRYSTAL A (LCSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 CRESCENT ST STE 202
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-3425
Mailing Address - Country:US
Mailing Address - Phone:781-487-1107
Mailing Address - Fax:
Practice Address - Street 1:8500 VILLAGE DR STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5510
Practice Address - Country:US
Practice Address - Phone:726-201-3047
Practice Address - Fax:833-629-0318
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
TX393211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical