Provider Demographics
NPI:1689688673
Name:BODEN, CANDACE I (LCSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:I
Last Name:BODEN
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 1:89 RICHARDS RD
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-3701
Mailing Address - Country:US
Mailing Address - Phone:860-567-7792
Mailing Address - Fax:
Practice Address - Street 1:89 RICHARDS RD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3701
Practice Address - Country:US
Practice Address - Phone:860-567-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0040741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004258382Medicaid
CTD400007063Medicare PIN