Healthcare Provider Details

I. General information

NPI: 1265656607
Provider Name (Legal Business Name): CHRISTINA R CANDELARIA LICENSED CLINICAL SO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 SAN PEDRO NE #A #A
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

1610 SAN PEDRO NE #A #A
ALBUQUERQUE NM
87110
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-0753
  • Fax: 505-268-5722
Mailing address:
  • Phone: 505-265-0753
  • Fax: 505-268-5722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM 5252
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: