Provider Demographics
NPI:1376817429
Name:KENT CANDELORA, PHD, A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:KENT CANDELORA, PHD, A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDELORA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:818-790-0150
Mailing Address - Street 1:1530 E CHEVY CHASE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4139
Mailing Address - Country:US
Mailing Address - Phone:818-790-0150
Mailing Address - Fax:
Practice Address - Street 1:1530 E CHEVY CHASE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4139
Practice Address - Country:US
Practice Address - Phone:818-790-0150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5341103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty