MEDICARE: MR. DANNY L RANDOLPH LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MT1361	FL

General Provider Information

NPI Number	:	1790787281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANNY L RANDOLPH LMFT

Provider Business Mailing Address
First Line	:	8478 RED HOLLY LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32221-1545
Country	:	US
Telephone Number	:	904-783-1956
Fax Number	:

Provider Business Practice Location Address
First Line	:	8478 RED HOLLY LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32221-1545
Country	:	US
Telephone Number	:	904-783-1956
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	07/08/2007

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