MEDICARE: DR. AUSTIN GONZALEZ-RANDOLPH LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	4078-57	WI
2	103T00000X	Psychologist	PY61278527	WA

General Provider Information

NPI Number	:	1851975056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUSTIN GONZALEZ-RANDOLPH LP

Provider Business Mailing Address
First Line	:	100 N HOWARD ST STE R
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99201-0508
Country	:	US
Telephone Number	:	425-780-5094
Fax Number	:

Provider Business Practice Location Address
First Line	:	712 MONROE AVE
Second Line	:
City	:	SOUTH MILWAUKEE
State	:	WI
Zip	:	53172-2126
Country	:	US
Telephone Number	:	425-780-5094
Fax Number	:	425-537-6473

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2021
Last Update Date	:	06/24/2025

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