Provider Demographics
NPI:1194885475
Name:ELKINS, RANDELL LEON JR (PHD)
Entity type:Individual
Prefix:
First Name:RANDELL
Middle Name:LEON
Last Name:ELKINS
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:701 BROAD ST STE 350
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3092
Practice Address - Country:US
Practice Address - Phone:706-295-2028
Practice Address - Fax:706-295-2062
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000948103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000493083BMedicaid
GA68BBDVLMedicare ID - Type Unspecified
GA000493083BMedicaid