Provider Demographics
NPI:1508160037
Name:LONG, CANDICE MICHELLE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:MICHELLE
Last Name:LONG
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 1:3663 PACIFIC AVE
Mailing Address - Street 2:P.O. BOX 2190
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-7062
Mailing Address - Country:US
Mailing Address - Phone:925-449-5845
Mailing Address - Fax:
Practice Address - Street 1:3663 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-7062
Practice Address - Country:US
Practice Address - Phone:925-449-5845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist