Provider Demographics
NPI:1427294065
Name:RANDOLPH, HEATHER (CCC-SLP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10323 ROSS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-8441
Mailing Address - Country:US
Mailing Address - Phone:478-319-1120
Mailing Address - Fax:
Practice Address - Street 1:10255 LAMBERT RD
Practice Address - Street 2:
Practice Address - City:PEYTON
Practice Address - State:CO
Practice Address - Zip Code:80831-3800
Practice Address - Country:US
Practice Address - Phone:719-495-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-04
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006967235Z00000X
CO24433858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist