Healthcare Provider Details

I. General information

NPI: 1225635303
Provider Name (Legal Business Name): CHRISTOPHER AARON RANDOLPH PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3827 ROUTE 100
PITTSFIELD VT
05762
US

IV. Provider business mailing address

PO BOX 729
KILLINGTON VT
05751-0729
US

V. Phone/Fax

Practice location:
  • Phone: 952-212-8216
  • Fax:
Mailing address:
  • Phone: 952-212-8216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number048.0111408
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: