Basic Information
| Provider Information | |||||||||
| NPI: | 1194885475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELKINS | ||||||||
| FirstName: | RANDELL | ||||||||
| MiddleName: | LEON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 TECHNOLOGY PKWY NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7622351000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 BROAD ST STE 350 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062952028 | ||||||||
| FaxNumber: | 7062952062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2006 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY000948 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000493083B | 05 | GA | MEDICAID |