Provider Demographics
NPI:1689907370
Name:FANALE, CANDACE (PHD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:FANALE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 W POINT LOMA BLVD
Mailing Address - Street 2:STE #56720
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4907 MORENA BLVD STE 1412
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-7391
Practice Address - Country:US
Practice Address - Phone:858-247-2417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-12
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA30957103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689907370OtherN/A