Healthcare Provider Details

I. General information

NPI: 1689453375
Provider Name (Legal Business Name): MISS BRITTANY SHEA RANDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 2ND ST
HENDERSON KY
42420-3231
US

IV. Provider business mailing address

109 GREENVILLE ST
DAWSON SPRINGS KY
42408-1214
US

V. Phone/Fax

Practice location:
  • Phone: 270-860-9594
  • Fax:
Mailing address:
  • Phone: 270-896-8541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: