Healthcare Provider Details

I. General information

NPI: 1558825984
Provider Name (Legal Business Name): CANDISE LIVERPOOL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 MARLBORO PIKE SUITE 100
UPPER MARLBORO MD
20772
US

IV. Provider business mailing address

9440 MARLBORO PIKE SUITE 100
UPPER MARLBORO MD
20772
US

V. Phone/Fax

Practice location:
  • Phone: 240-243-9599
  • Fax:
Mailing address:
  • Phone: 240-243-9599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: