Provider Demographics
NPI:1467700492
Name:RADMALL, CANDICE (LPC)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:RADMALL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 S BRIDGEWAY PL
Mailing Address - Street 2:STE 100
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-246-0123
Mailing Address - Fax:
Practice Address - Street 1:1032 S BRIDGEWAY PL
Practice Address - Street 2:STE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-246-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5051101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health