Provider Demographics
NPI:1568891018
Name:SAM, CANDACE (LICSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 HAVELOCK AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68507-1268
Mailing Address - Country:US
Mailing Address - Phone:702-353-0952
Mailing Address - Fax:844-329-1465
Practice Address - Street 1:6101 HAVELOCK AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68507-1268
Practice Address - Country:US
Practice Address - Phone:702-353-0952
Practice Address - Fax:844-329-1465
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14831041C0700X
NE1611104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker