Provider Demographics
NPI:1225224140
Name:THOMAS, CANDICE TISDALE (LCSWC ACSW)
Entity Type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:TISDALE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSWC ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5521
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21285
Mailing Address - Country:US
Mailing Address - Phone:443-798-8832
Mailing Address - Fax:443-660-8113
Practice Address - Street 1:408 ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4252
Practice Address - Country:US
Practice Address - Phone:443-798-8832
Practice Address - Fax:443-660-8113
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD135761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD320257229Medicaid