Provider Demographics
NPI:1346465606
Name:CANDY, RAVENNA
Entity Type:Individual
Prefix:
First Name:RAVENNA
Middle Name:
Last Name:CANDY
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 1:1010 S 146TH ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98168-3669
Mailing Address - Country:US
Mailing Address - Phone:206-241-0990
Mailing Address - Fax:
Practice Address - Street 1:1010 S 146TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98168-3669
Practice Address - Country:US
Practice Address - Phone:206-241-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007991101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health