Provider Demographics
NPI:1336425735
Name:LIDER, CANDACE GOULD (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:GOULD
Last Name:LIDER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:CANDACE
Other - Middle Name:GOULD
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:1501 SIVER RD
Mailing Address - Street 2:
Mailing Address - City:GUILDERLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12084-9775
Mailing Address - Country:US
Mailing Address - Phone:518-357-2802
Mailing Address - Fax:
Practice Address - Street 1:10 EMPIRE STATE BLVD
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9751
Practice Address - Country:US
Practice Address - Phone:518-477-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-30
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009215-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist