Provider Demographics
NPI:1922557123
Name:MIREA, CANDACE (LCSW, LAC)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:
Last Name:MIREA
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 CONNERY WAY STE B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1955
Mailing Address - Country:US
Mailing Address - Phone:208-502-0664
Mailing Address - Fax:
Practice Address - Street 1:2809 CONNERY WAY STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1955
Practice Address - Country:US
Practice Address - Phone:208-502-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-18799101YA0400X
MTBBH-LCSW-LIC-328961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)