Provider Demographics
NPI:1134169790
Name:WASHINGTON, CANDACE LOUISE (PHD)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:LOUISE
Last Name:WASHINGTON
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 1:4265 BROWNSBORO RD STE 150
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-6194
Mailing Address - Country:US
Mailing Address - Phone:336-896-0700
Mailing Address - Fax:336-896-0701
Practice Address - Street 1:4265 BROWNSBORO RD
Practice Address - Street 2:SUITE 150
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3425
Practice Address - Country:US
Practice Address - Phone:336-896-0700
Practice Address - Fax:336-896-0701
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2713103TC0700X, 103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000887Medicaid
NC2823140Medicare PIN