MEDICARE: PATRICIA RANDOLPH MA, PH.D

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	101YM0800X	Mental Health Counselor	MFC25109	CA

General Provider Information

NPI Number	:	1942345632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA RANDOLPH MA, PH.D

Provider Business Mailing Address
First Line	:	2201 SANTA ANITA AVE
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-2918
Country	:	US
Telephone Number	:	626-482-4021
Fax Number	:	951-898-9858

Provider Business Practice Location Address
First Line	:	2900 ADAMS ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-4335
Country	:	US
Telephone Number	:	951-205-5883
Fax Number	:	951-898-9858

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

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	07/08/2007

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