Provider Demographics
NPI:1578172482
Name:BOLZ, CANDACE (LAC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:BOLZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18285 ROLLER COASTER RD
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8352
Mailing Address - Country:US
Mailing Address - Phone:303-875-7438
Mailing Address - Fax:
Practice Address - Street 1:18743 ROLLER COASTER RD
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-8352
Practice Address - Country:US
Practice Address - Phone:303-875-7438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000929101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)