Provider Demographics
NPI:1366772881
Name:RANDOLPH, KAREN MARIE (MPT, COMT)
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:MARIE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MPT, COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 FALL RIVER LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-8501
Mailing Address - Country:US
Mailing Address - Phone:314-791-5884
Mailing Address - Fax:
Practice Address - Street 1:9437 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-3130
Practice Address - Country:US
Practice Address - Phone:314-989-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009038744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist