Provider Demographics
NPI:1659482131
Name:MULLENDORE, CANDICE J (OTRL)
Entity Type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:J
Last Name:MULLENDORE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:CANDICE
Other - Middle Name:SALE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10601 S 72ND ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-3407
Mailing Address - Country:US
Mailing Address - Phone:402-932-2782
Mailing Address - Fax:
Practice Address - Street 1:10601 S 72ND ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-3407
Practice Address - Country:US
Practice Address - Phone:402-932-2782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE830225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist