Provider Demographics
NPI:1477894129
Name:LOPEZ, CANDACE MARIE (MSW PCSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARIE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MSW PCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 KIT CARSON AVE
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-3115
Mailing Address - Country:US
Mailing Address - Phone:307-258-9956
Mailing Address - Fax:
Practice Address - Street 1:2521 E 15TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4126
Practice Address - Country:US
Practice Address - Phone:307-258-9956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPCSW-5021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical