Provider Demographics
NPI:1205886561
Name:POWELL, CANDYCE ANN (MPT)
Entity type:Individual
Prefix:
First Name:CANDYCE
Middle Name:ANN
Last Name:POWELL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 ROWLAND WAY STE 250
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-5062
Mailing Address - Country:US
Mailing Address - Phone:415-898-1311
Mailing Address - Fax:415-897-0741
Practice Address - Street 1:88 ROWLAND WAY STE 250
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5062
Practice Address - Country:US
Practice Address - Phone:415-898-1311
Practice Address - Fax:415-897-0741
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10998225100000X
CA24218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT242180Medicare ID - Type UnspecifiedPHYSICAL THERAPY MEDICARE