Provider Demographics
NPI:1043512916
Name:OLGUIN, CANDACE M (BS)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:M
Last Name:OLGUIN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1520
Mailing Address - Country:US
Mailing Address - Phone:719-561-9850
Mailing Address - Fax:
Practice Address - Street 1:2039 E 10TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-3421
Practice Address - Country:US
Practice Address - Phone:719-250-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12570324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility