Provider Demographics
NPI:1215704986
Name:RANDOLPH, HOLLY NICOLE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:NICOLE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3806 E SHAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-9637
Mailing Address - Country:US
Mailing Address - Phone:615-961-3017
Mailing Address - Fax:
Practice Address - Street 1:4066 E MONSANTO DR UNIT E
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650-8512
Practice Address - Country:US
Practice Address - Phone:520-335-6118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-20787104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker