Healthcare Provider Details

I. General information

NPI: 1801107339
Provider Name (Legal Business Name): MRS. VERGIA HEADSPETH-RANDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 01/19/2025
Certification Date: 01/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9411 TEMPLE HILL RD
CLINTON MD
20735-4434
US

IV. Provider business mailing address

9411 TEMPLE HILL RD
CLINTON MD
20735-4434
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-9423
  • Fax:
Mailing address:
  • Phone: 301-877-9423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberOT100000126
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number04264
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT100000126
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number100000126
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: