Provider Demographics
NPI:1770632317
Name:CANDELORA, KENT (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:
Last Name:CANDELORA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 E CHEVY CHASE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4139
Mailing Address - Country:US
Mailing Address - Phone:818-790-0150
Mailing Address - Fax:818-243-7518
Practice Address - Street 1:1530 E CHEVY CHASE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4139
Practice Address - Country:US
Practice Address - Phone:818-790-0150
Practice Address - Fax:818-243-7518
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5341103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5341Medicare UPIN