Provider Demographics
NPI:1154290757
Name:RANDOLPH, LORI (LCSW, PEL, CYT 200)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LCSW, PEL, CYT 200
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 STATE ROUTE 127 S
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62952-1326
Mailing Address - Country:US
Mailing Address - Phone:618-685-0580
Mailing Address - Fax:
Practice Address - Street 1:2805 STATE ROUTE 127 S
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:IL
Practice Address - Zip Code:62952-1326
Practice Address - Country:US
Practice Address - Phone:618-685-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-03
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0303351041C0700X
IL25461821041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool