Provider Demographics
NPI:1053028647
Name:RANDOLPH, EMILY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CHRISTOPHER LN
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2827
Mailing Address - Country:US
Mailing Address - Phone:856-404-1286
Mailing Address - Fax:
Practice Address - Street 1:630 E CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-1828
Practice Address - Country:US
Practice Address - Phone:302-454-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEO10012149235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEERANDOLPH16Medicaid