Provider Demographics
NPI:1295190155
Name:MCCANDLISH, JOANNA
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:MCCANDLISH
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 1:2726 BRUCHEZ PKWY UNIT 204
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-3583
Mailing Address - Country:US
Mailing Address - Phone:757-784-6459
Mailing Address - Fax:
Practice Address - Street 1:2726 BRUCHEZ PKWY UNIT 204
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-3583
Practice Address - Country:US
Practice Address - Phone:757-784-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-20
Last Update Date:2015-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0013352225200000X
VA2306604331225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant