Provider Demographics
NPI:1972903946
Name:CEPEDA, CANDICE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:CEPEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 SPRING ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1817
Practice Address - Country:US
Practice Address - Phone:631-476-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024934-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024934-1OtherNEW YORK STATE SPEECH LANGUAGE PATHOLOGIST LICENSE