Provider Demographics
NPI:1154932903
Name:RANDOLPH, KATELYNN ROSE (BS)
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:ROSE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:KATELYNN
Other - Middle Name:ROSE
Other - Last Name:RUHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:1455 OLD ALABAMA RD STE 195
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2129
Practice Address - Country:US
Practice Address - Phone:678-940-1367
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-19-90909106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician