Provider Demographics
NPI:1912875691
Name:RANDOLPH, KIRSTEN GRAHAM
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:GRAHAM
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 HONEYSUCKLE DR
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2841
Mailing Address - Country:US
Mailing Address - Phone:919-260-6832
Mailing Address - Fax:
Practice Address - Street 1:725 N HIGHWAY A1A STE A104
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-4561
Practice Address - Country:US
Practice Address - Phone:561-808-5201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-25
Last Update Date:2025-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW216911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical