Provider Demographics
NPI:1750948980
Name:SMITH, CANDACE LARAE (LMT)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:LARAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:LARAE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:925 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-6304
Mailing Address - Country:US
Mailing Address - Phone:206-631-2819
Mailing Address - Fax:
Practice Address - Street 1:925 8TH AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-6304
Practice Address - Country:US
Practice Address - Phone:206-631-2819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMA60795955225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60795955OtherMASSAGE LICENSE