Healthcare Provider Details

I. General information

NPI: 1790822856
Provider Name (Legal Business Name): CORLIS YVONNE RANDOLPH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CORLIS RANDOLPH JEFFRESS MSW

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 12TH ST NE
WASHINGTON DC
20002-4462
US

IV. Provider business mailing address

823 12TH ST NE
WASHINGTON DC
20002-4462
US

V. Phone/Fax

Practice location:
  • Phone: 202-397-5042
  • Fax: 202-397-1684
Mailing address:
  • Phone: 202-397-5042
  • Fax: 202-397-1684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC301584
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: