Provider Demographics
NPI:1871352617
Name:RANDOLPH, CASSANDRA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 OLIVE AVE # 177
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5142
Mailing Address - Country:US
Mailing Address - Phone:714-951-1534
Mailing Address - Fax:
Practice Address - Street 1:3420 BRISTOL ST FL 6
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7170
Practice Address - Country:US
Practice Address - Phone:714-794-2034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35561235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist