Healthcare Provider Details

I. General information

NPI: 1104991322
Provider Name (Legal Business Name): CANDACE WARD-MCKINLAY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2271 ALPINE BLVD STE A
ALPINE CA
91901-1101
US

IV. Provider business mailing address

2966 NIGHT WATCH WAY
ALPINE CA
91901-4115
US

V. Phone/Fax

Practice location:
  • Phone: 203-848-9716
  • Fax:
Mailing address:
  • Phone: 203-848-9716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY7379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: