Provider Demographics
NPI:1093939399
Name:AHN, RANDALL LEE (PHD, MLIS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LEE
Last Name:AHN
Suffix:
Gender:M
Credentials:PHD, MLIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 E 17TH ST # 1029
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3831
Mailing Address - Country:US
Mailing Address - Phone:949-414-7149
Mailing Address - Fax:
Practice Address - Street 1:800 FERRARI STE 200
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5031
Practice Address - Country:US
Practice Address - Phone:909-244-9593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13956103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY13956OtherPSYCHOLOGY LICENSE
CAPSY13956OtherPSYCHOLOGY LICENSE