Provider Demographics
NPI:1780110692
Name:WHITE, CANDIS (RBT)
Entity type:Individual
Prefix:
First Name:CANDIS
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 HUGO ST
Mailing Address - Street 2:APT 3
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2738
Mailing Address - Country:US
Mailing Address - Phone:310-691-3644
Mailing Address - Fax:
Practice Address - Street 1:139 HUGO ST
Practice Address - Street 2:APT 3
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-2738
Practice Address - Country:US
Practice Address - Phone:310-691-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15-06339106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician