Provider Demographics
NPI:1720231376
Name:CANDELARIA, BOBBY G (LADAC)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:G
Last Name:CANDELARIA
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 W FIRWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-5020
Mailing Address - Country:US
Mailing Address - Phone:505-632-8075
Mailing Address - Fax:
Practice Address - Street 1:205 N AUBURN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8411
Practice Address - Country:US
Practice Address - Phone:505-564-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0069761101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)