Provider Demographics
NPI:1457404188
Name:ALLE-CORLISS, RANDALL M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:M
Last Name:ALLE-CORLISS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9310 SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-5711
Mailing Address - Country:US
Mailing Address - Phone:909-427-3788
Mailing Address - Fax:909-427-3750
Practice Address - Street 1:9310 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5711
Practice Address - Country:US
Practice Address - Phone:909-427-3788
Practice Address - Fax:909-427-3750
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 96461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical