Healthcare Provider Details

I. General information

NPI: 1851742886
Provider Name (Legal Business Name): CANDICE HOKE KENNEDY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CANDICE KENNEDY PH.D.

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 08/17/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

913 GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone: 541-440-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberGRADUATE
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: