Provider Demographics
NPI:1578240990
Name:CANDAMO, LOUCEL
Entity Type:Individual
Prefix:
First Name:LOUCEL
Middle Name:
Last Name:CANDAMO
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 1:12406 NE 21ST ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5512
Mailing Address - Country:US
Mailing Address - Phone:360-843-6663
Mailing Address - Fax:
Practice Address - Street 1:9901 NE 7TH AVE STE C116
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-4528
Practice Address - Country:US
Practice Address - Phone:503-254-6317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician