Provider Demographics
NPI:1649659566
Name:CANADA, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:CANADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 TERRAPIN HILLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1725 TERRAPIN HILLS DR
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-2739
Practice Address - Country:US
Practice Address - Phone:301-808-2214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0976101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor