Provider Demographics
NPI:1932749710
Name:RANDOLPH, ALEXANDRIA MARIE (OT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:MARIE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ALEXANDRIA
Other - Middle Name:MARIE
Other - Last Name:HOLLINGSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:100 TRACEY CV
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 LEXINGTON DR STE H
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6646
Practice Address - Country:US
Practice Address - Phone:601-910-7300
Practice Address - Fax:601-910-7071
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT3515225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSOT3515OtherMISSISSIPI DEPARTMENT OF LICENSURE