Provider Demographics
NPI:1093911828
Name:CANDLEWOOD FAMILY COUNSELING CENTER, INC.
Entity Type:Organization
Organization Name:CANDLEWOOD FAMILY COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:DINGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, ACSW
Authorized Official - Phone:208-478-8340
Mailing Address - Street 1:PO BOX 2306
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83206-2306
Mailing Address - Country:US
Mailing Address - Phone:208-478-8340
Mailing Address - Fax:208-478-8341
Practice Address - Street 1:335 N MAIN ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3108
Practice Address - Country:US
Practice Address - Phone:208-478-8340
Practice Address - Fax:208-478-8341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1093911828Medicaid
ID1588860308Medicaid
ID1912103748Medicaid
ID1174673305OtherPRIVATE INSURANCE
ID1831395656Medicaid