Provider Demographics
NPI:1427289503
Name:RANDOLPH, PEGGY ANN (LCSW)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7881 NEWMAN AVE
Mailing Address - Street 2:#C
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-6829
Mailing Address - Country:US
Mailing Address - Phone:714-334-6541
Mailing Address - Fax:714-334-6541
Practice Address - Street 1:7881 NEWMAN AVE
Practice Address - Street 2:#C
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6829
Practice Address - Country:US
Practice Address - Phone:714-334-6541
Practice Address - Fax:714-334-6541
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251161041C0700X
TN0031941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical