Provider Demographics
NPI:1124008305
Name:RANDOLPH, TRACY LEIGH (MS)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEIGH
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LEIGH
Other - Last Name:MAYNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3768 HICKORY MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6417
Mailing Address - Country:US
Mailing Address - Phone:770-831-2726
Mailing Address - Fax:
Practice Address - Street 1:4129 SHADY DR NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2647
Practice Address - Country:US
Practice Address - Phone:770-925-9543
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist