Provider Demographics
NPI:1265656607
Name:CANDELARIA, CHRISTINA R (LICENSED CLINICAL SO)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:R
Last Name:CANDELARIA
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 SAN PEDRO NE #A
Mailing Address - Street 2:#A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-265-0753
Mailing Address - Fax:505-268-5722
Practice Address - Street 1:1610 SAN PEDRO NE #A
Practice Address - Street 2:#A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-265-0753
Practice Address - Fax:505-268-5722
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM 52521041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72073730Medicaid