Provider Demographics
NPI:1790822856
Name:RANDOLPH, CORLIS YVONNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CORLIS
Middle Name:YVONNE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CORLIS
Other - Middle Name:RANDOLPH
Other - Last Name:JEFFRESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:823 12TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4462
Mailing Address - Country:US
Mailing Address - Phone:202-397-5042
Mailing Address - Fax:202-397-1684
Practice Address - Street 1:823 12TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4462
Practice Address - Country:US
Practice Address - Phone:202-397-5042
Practice Address - Fax:202-397-1684
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3015841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical