Provider Demographics
NPI:1407439805
Name:CHRISTIANSON, CANDACE GRAVES (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:GRAVES
Last Name:CHRISTIANSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 OAKESDALE DR
Mailing Address - Street 2:
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7818
Mailing Address - Country:US
Mailing Address - Phone:843-298-1617
Mailing Address - Fax:
Practice Address - Street 1:110 PIPEMAKERS CIR STE 115
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4168
Practice Address - Country:US
Practice Address - Phone:912-988-1526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011474235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist