Provider Demographics
NPI:1801810122
Name:BROWN, CANDACE MARIE (PT)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARIE
Last Name:BROWN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:M
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:3266 FLUVANNA AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:FLUVANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9706
Mailing Address - Country:US
Mailing Address - Phone:716-708-6179
Mailing Address - Fax:866-902-1160
Practice Address - Street 1:3266 FLUVANNA AVENUE EXT
Practice Address - Street 2:
Practice Address - City:FLUVANNA
Practice Address - State:NY
Practice Address - Zip Code:14701-9706
Practice Address - Country:US
Practice Address - Phone:716-708-6179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025134225100000X
NY025134-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02650273Medicaid
NYRA8171Medicare UPIN
NYAA0830Medicare ID - Type Unspecified
RA8171Medicare UPIN