Provider Demographics
NPI:1821640806
Name:CANDELARIA, GARRET
Entity Type:Individual
Prefix:
First Name:GARRET
Middle Name:
Last Name:CANDELARIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E VAN BUREN ST APT 1116
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-4028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9980 W GLENDALE AVE STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-3005
Practice Address - Country:US
Practice Address - Phone:623-226-8804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007836225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand