Provider Demographics
NPI:1396307070
Name:BROWN, KALISHA KORAN (LCSW)
Entity type:Individual
Prefix:
First Name:KALISHA KORAN
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KALISHA KORAN
Other - Middle Name:
Other - Last Name:VAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:12139 MOUNT VERNON AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5500
Mailing Address - Country:US
Mailing Address - Phone:909-222-0096
Mailing Address - Fax:
Practice Address - Street 1:12139 MOUNT VERNON AVE STE 105
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5500
Practice Address - Country:US
Practice Address - Phone:909-222-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA999951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF9756Medicaid
F9756OtherPRIVATE INSURANCE