Provider Demographics
NPI:1114947561
Name:NATTLAND, CANDICE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:
Last Name:NATTLAND
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1631
Mailing Address - Country:US
Mailing Address - Phone:973-783-2110
Mailing Address - Fax:908-475-3328
Practice Address - Street 1:25 GROVE AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1631
Practice Address - Country:US
Practice Address - Phone:973-783-2110
Practice Address - Fax:908-475-3328
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2103103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ541464Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER