Provider Demographics
NPI:1831389329
Name:BETTY, CANDICE LORRAINE (LMT)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:LORRAINE
Last Name:BETTY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19631 LORNE ST
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-1026
Mailing Address - Country:US
Mailing Address - Phone:818-419-7052
Mailing Address - Fax:818-885-5760
Practice Address - Street 1:19631 LORNE ST
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-1026
Practice Address - Country:US
Practice Address - Phone:818-419-7052
Practice Address - Fax:818-885-5760
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2206618 P955225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist