Provider Demographics
NPI:1487696548
Name:RANDOLPH, GENA C (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:GENA
Middle Name:C
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1150 HUNGRYNECK BLVD
Mailing Address - Street 2:SUITE C-364
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3484
Mailing Address - Country:US
Mailing Address - Phone:843-388-9990
Mailing Address - Fax:843-388-0349
Practice Address - Street 1:1150 HUNGRYNECK BLVD
Practice Address - Street 2:SUITE C-364
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3484
Practice Address - Country:US
Practice Address - Phone:843-388-9990
Practice Address - Fax:843-388-0349
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC3120235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist