Provider Demographics
NPI:1437520715
Name:WALLS, CANDACE SHANTE
Entity Type:Individual
Prefix:MISS
First Name:CANDACE
Middle Name:SHANTE
Last Name:WALLS
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 1:811 GRAND AVE STE D
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3466
Mailing Address - Country:US
Mailing Address - Phone:916-009-8952
Mailing Address - Fax:
Practice Address - Street 1:2020 29TH ST STE 201
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1119
Practice Address - Country:US
Practice Address - Phone:510-292-8539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138953106H00000X
CAIMF89638106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1437520715Medicaid