Provider Demographics
NPI:1912638552
Name:JOHNSON, CANDACE RAE (LGSW, LADC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LGSW, LADC
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:RAE
Other - Last Name:BARTHEIDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:2230 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2230 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1720
Practice Address - Country:US
Practice Address - Phone:612-730-9429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30874390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program