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General NPI Number Information
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NPI Number | 1093939399
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Entity Type | Individual
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Provider Name | RANDALL LEE AHN PHD, MLIS
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Gender | Male
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 05/07/2024
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Provider Practice Location Address
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Address Line | 16465 SIERRA LAKES PKWY STE 140
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City | FONTANA
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State | CA
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Zip | 92336-1242
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Country | US
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Telephone | 909-244-9593
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Fax | 833-903-0337
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Provider Business Mailing Address
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Address Line | 241 E 17TH ST # 1029
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City | COSTA MESA
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State | CA
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Zip | 92627-3831
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Country | US
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Telephone | 949-414-7149
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | PSY13956
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License Number State | CA
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