Healthcare Provider Details

I. General information

NPI: 1811463797
Provider Name (Legal Business Name): CRYSTAL A RANDOLPH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 VILLAGE DR STE 101
SAN ANTONIO TX
78217-5510
US

IV. Provider business mailing address

221 CRESCENT ST STE 202
WALTHAM MA
02453-3425
US

V. Phone/Fax

Practice location:
  • Phone: 726-201-3047
  • Fax: 833-629-0318
Mailing address:
  • Phone: 781-487-1107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number39321
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: