Provider Demographics
NPI:1952309395
Name:LUTES, CANDIDA JANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CANDIDA
Middle Name:JANE
Last Name:LUTES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 OAK LAWN AVE.
Mailing Address - Street 2:SUITE 275
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4308
Mailing Address - Country:US
Mailing Address - Phone:214-522-0498
Mailing Address - Fax:214-522-0454
Practice Address - Street 1:3500 OAK LAWN AVE.
Practice Address - Street 2:SUITE 275
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4308
Practice Address - Country:US
Practice Address - Phone:214-522-0498
Practice Address - Fax:214-522-0454
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21711103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00334369-01Medicaid
TX0334379-01Medicaid
TX0334379-01Medicaid