Healthcare Provider Details

I. General information

NPI: 1740267285
Provider Name (Legal Business Name): PATRICK D RANDOLPH PHD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 01/04/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5147 69TH ST STE D
LUBBOCK TX
79424-1646
US

IV. Provider business mailing address

5147 69TH ST STE D
LUBBOCK TX
79424-1646
US

V. Phone/Fax

Practice location:
  • Phone: 806-771-8808
  • Fax: 806-771-8809
Mailing address:
  • Phone: 806-771-8808
  • Fax: 806-771-8809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number24796
License Number StateTX

VIII. Authorized Official

Name: STEPHANIE STIMAC
Title or Position: OFFICE MANAGER
Credential:
Phone: 806-771-8808