Provider Demographics
NPI:1578575080
Name:LOUISE, CANDICE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:
Last Name:LOUISE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 VIA MARINA APT B208
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-4404
Mailing Address - Country:US
Mailing Address - Phone:208-871-0899
Mailing Address - Fax:
Practice Address - Street 1:4015 VIA MARINA APT B208
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-4404
Practice Address - Country:US
Practice Address - Phone:208-871-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-260091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010153443Medicare UPIN
IDL5766Medicare UPIN