Provider Demographics
NPI:1700549391
Name:DAN, CANDACE L (LMSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:L
Last Name:DAN
Suffix:
Gender:F
Credentials:LMSW
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 1421
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87416-1421
Mailing Address - Country:US
Mailing Address - Phone:505-516-7767
Mailing Address - Fax:
Practice Address - Street 1:208 E APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6904
Practice Address - Country:US
Practice Address - Phone:505-327-1244
Practice Address - Fax:505-325-7803
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-11254104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker