Provider Demographics
NPI:1407191596
Name:MONDRAGON, CANDICE ROSE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:ROSE
Last Name:MONDRAGON
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 1:1675 SKY MOUNTAIN DR
Mailing Address - Street 2:132
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-9193
Mailing Address - Country:US
Mailing Address - Phone:775-220-4211
Mailing Address - Fax:
Practice Address - Street 1:1101 W MOANA LN
Practice Address - Street 2:SUITE 2
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4775
Practice Address - Country:US
Practice Address - Phone:775-337-2394
Practice Address - Fax:775-337-9570
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst