Provider Demographics
NPI:1831592054
Name:HENDERSON, CANDICE
Entity type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:
Last Name:HENDERSON
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 1:1141 HOLLYWOOD RD
Mailing Address - Street 2:APT. B
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-5629
Mailing Address - Country:US
Mailing Address - Phone:908-591-3296
Mailing Address - Fax:
Practice Address - Street 1:1141 HOLLYWOOD RD APT B
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-5629
Practice Address - Country:US
Practice Address - Phone:908-591-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY860100141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist