Provider Demographics
NPI:1154971182
Name:RANDOL, TARA LYNN
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:RANDOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 BOSTWYCK DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-7525
Mailing Address - Country:US
Mailing Address - Phone:808-346-5651
Mailing Address - Fax:
Practice Address - Street 1:1305 DARES BEACH RD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4208
Practice Address - Country:US
Practice Address - Phone:443-550-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09215235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist