Healthcare Provider Details

I. General information

NPI: 1871530410
Provider Name (Legal Business Name): RANDOLPH S IMHOFF LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S WASHINGTON ST SUITE 1
CARTHAGE NY
13619-1534
US

IV. Provider business mailing address

500 S WASHINGTON ST SUITE 1
CARTHAGE NY
13619-1534
US

V. Phone/Fax

Practice location:
  • Phone: 315-493-4900
  • Fax: 315-493-4909
Mailing address:
  • Phone: 315-493-4900
  • Fax: 315-493-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000295
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: