Provider Demographics
NPI:1346882453
Name:WOLLE, CANDISS NICOLE (SWC)
Entity Type:Individual
Prefix:
First Name:CANDISS
Middle Name:NICOLE
Last Name:WOLLE
Suffix:
Gender:F
Credentials:SWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1581
Mailing Address - Street 2:
Mailing Address - City:DOLORES
Mailing Address - State:CO
Mailing Address - Zip Code:81323-1581
Mailing Address - Country:US
Mailing Address - Phone:719-619-6676
Mailing Address - Fax:
Practice Address - Street 1:418 S SLIGO ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-4718
Practice Address - Country:US
Practice Address - Phone:970-565-4855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSWC00000012021041C0700X
CORBT-19-101341106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician