Provider Demographics
NPI:1508341215
Name:SURH, CANDICE YPUJIN
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:YPUJIN
Last Name:SURH
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 1:1301 W PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3808
Mailing Address - Country:US
Mailing Address - Phone:714-639-4991
Mailing Address - Fax:
Practice Address - Street 1:1301 W PROVIDENCE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3808
Practice Address - Country:US
Practice Address - Phone:714-639-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-63337106S00000X
CA16077235Z00000X
235Z00000X
CA34200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician