Provider Demographics
NPI:1922674571
Name:SA, CANDICE (QMHA)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:SA
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LOTUS CIR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-7512
Mailing Address - Country:US
Mailing Address - Phone:702-494-7763
Mailing Address - Fax:
Practice Address - Street 1:777 E WILLIAM ST STE 102
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-4057
Practice Address - Country:US
Practice Address - Phone:775-434-7103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8448-S261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health