Provider Demographics
NPI:1629460290
Name:RICHARDSON, CANDICE SHAVON (LMFT)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:SHAVON
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9329
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-1329
Mailing Address - Country:US
Mailing Address - Phone:707-280-3895
Mailing Address - Fax:
Practice Address - Street 1:5119 LISA WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-3744
Practice Address - Country:US
Practice Address - Phone:707-888-2048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLMFT202549106H00000X
CALMFT85376106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist