Healthcare Provider Details

I. General information

NPI: 1962322362
Provider Name (Legal Business Name): QUINTEN RANDOLPH LGPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5406 DOLE ST
CAPITOL HEIGHTS MD
20743-6221
US

IV. Provider business mailing address

750 PORT ST APT 2132
ALEXANDRIA VA
22314-6476
US

V. Phone/Fax

Practice location:
  • Phone: 240-605-6315
  • Fax:
Mailing address:
  • Phone: 240-605-6315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP18028
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: