Healthcare Provider Details

I. General information

NPI: 1922674571
Provider Name (Legal Business Name): CANDICE SA QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 FLEISCHMANN WAY
CARSON CITY NV
89703-2995
US

IV. Provider business mailing address

200 LOTUS CIR
CARSON CITY NV
89703-7512
US

V. Phone/Fax

Practice location:
  • Phone: 754-458-8889
  • Fax:
Mailing address:
  • Phone: 702-494-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11975-C
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberIC1874
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14307137-3501
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number8448-S
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: