Provider Demographics
NPI:1235554932
Name:WALTERS, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36261 OKEFENOKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FOLKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:31537
Mailing Address - Country:US
Mailing Address - Phone:912-496-7396
Mailing Address - Fax:
Practice Address - Street 1:36261 OKEFENOKEE DR
Practice Address - Street 2:
Practice Address - City:FOLKSTON
Practice Address - State:GA
Practice Address - Zip Code:31537-7853
Practice Address - Country:US
Practice Address - Phone:912-496-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001650224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant