Provider Demographics
NPI:1003155078
Name:BLASE, CANDACE ANNE (LCPAT)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:ANNE
Last Name:BLASE
Suffix:
Gender:F
Credentials:LCPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14601 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:GLENELG
Mailing Address - State:MD
Mailing Address - Zip Code:21737-9611
Mailing Address - Country:US
Mailing Address - Phone:443-280-0677
Mailing Address - Fax:
Practice Address - Street 1:5560 STERRETT PL
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2601
Practice Address - Country:US
Practice Address - Phone:443-546-4000
Practice Address - Fax:443-546-4005
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATC003101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor