Provider Demographics
NPI:1407619737
Name:BALLSTADT, CANDACE JEAN (LSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:JEAN
Last Name:BALLSTADT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20325 410TH ST
Mailing Address - Street 2:
Mailing Address - City:GOODHUE
Mailing Address - State:MN
Mailing Address - Zip Code:55027-7006
Mailing Address - Country:US
Mailing Address - Phone:651-380-9528
Mailing Address - Fax:
Practice Address - Street 1:1415 TOWN SQUARE LN
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6088
Practice Address - Country:US
Practice Address - Phone:507-323-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical