Provider Demographics
NPI:1629533559
Name:CARR-CALLEN, CANDICE LYNN (AGENCY AFFILIATED)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:LYNN
Last Name:CARR-CALLEN
Suffix:
Gender:F
Credentials:AGENCY AFFILIATED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-3326
Mailing Address - Country:US
Mailing Address - Phone:509-624-3251
Mailing Address - Fax:
Practice Address - Street 1:812 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-3326
Practice Address - Country:US
Practice Address - Phone:509-624-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60606578101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health