Provider Demographics
NPI:1255737789
Name:RANDOLPH, BENJAMIN MATHIAS (MSW, SWLC, LAC)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:MATHIAS
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MSW, SWLC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-0122
Mailing Address - Country:US
Mailing Address - Phone:406-248-3175
Mailing Address - Fax:406-248-3821
Practice Address - Street 1:1231 N 29TH ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0122
Practice Address - Country:US
Practice Address - Phone:406-248-3175
Practice Address - Fax:406-248-3821
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT327691041C0700X
MTLAC-LAC-LIC-4198101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)