Provider Demographics
NPI:1740487164
Name:KANDIS, STEPHEN (MFT)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:KANDIS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23621 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-5743
Mailing Address - Country:US
Mailing Address - Phone:310-816-5358
Mailing Address - Fax:
Practice Address - Street 1:23621 MAIN ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-5743
Practice Address - Country:US
Practice Address - Phone:310-816-5358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT17893106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist