Provider Demographics
NPI:1265846638
Name:DOUGLAS, CANDACE (MA,ATC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MA,ATC
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,ATC
Mailing Address - Street 1:5450 MONTGOMERY SQUARE DR
Mailing Address - Street 2:APT G
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-2952
Mailing Address - Country:US
Mailing Address - Phone:937-367-3200
Mailing Address - Fax:
Practice Address - Street 1:5450 MONTGOMERY SQUARE DR
Practice Address - Street 2:APT G
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45440-2952
Practice Address - Country:US
Practice Address - Phone:937-367-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0035742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer