Provider Demographics
NPI:1225553084
Name:DARKASHADE, CANDRICK C
Entity Type:Individual
Prefix:DR
First Name:CANDRICK
Middle Name:C
Last Name:DARKASHADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 FOREST VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001
Mailing Address - Country:US
Mailing Address - Phone:848-467-1409
Mailing Address - Fax:
Practice Address - Street 1:285 ROSEVILLE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1703
Practice Address - Country:US
Practice Address - Phone:973-481-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ173-040103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty