Provider Demographics
NPI:1205099215
Name:MOHAMMAD, CANDICE KAE (LICSW)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:KAE
Last Name:MOHAMMAD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 FAIRMONT ST NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1667
Mailing Address - Country:US
Mailing Address - Phone:763-717-7979
Mailing Address - Fax:
Practice Address - Street 1:490 FAIRMONT ST NE
Practice Address - Street 2:NO BUSINESS
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-1667
Practice Address - Country:US
Practice Address - Phone:763-717-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical