Provider Demographics
NPI:1780099762
Name:BRAXTON, CANDACE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:BRAXTON
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 1:1220 E JUANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-3600
Mailing Address - Country:US
Mailing Address - Phone:313-378-8593
Mailing Address - Fax:
Practice Address - Street 1:17100 E SHEA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-6663
Practice Address - Country:US
Practice Address - Phone:480-221-2573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109913235Z00000X
AZSLP13592235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist