Provider Demographics
NPI:1497938864
Name:CANDELARIA, COREY A (LPC, MA CSPT, CSAT)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:A
Last Name:CANDELARIA
Suffix:
Gender:M
Credentials:LPC, MA CSPT, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 S. 88TH STREET
Mailing Address - Street 2:UNIT A
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-2444
Mailing Address - Country:US
Mailing Address - Phone:303-917-3114
Mailing Address - Fax:303-763-1871
Practice Address - Street 1:1068 S 88TH ST
Practice Address - Street 2:UNIT A
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9461
Practice Address - Country:US
Practice Address - Phone:303-917-3114
Practice Address - Fax:303-763-1871
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-08
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5569101YP2500X
5569103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5569OtherLPC