Healthcare Provider Details

I. General information

NPI: 1073718284
Provider Name (Legal Business Name): CANDICE M HOLM PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14150 PARKEAST CIR
CHANTILLY VA
20151-2295
US

IV. Provider business mailing address

14150 PARKEAST CIR
CHANTILLY VA
20151-2295
US

V. Phone/Fax

Practice location:
  • Phone: 703-968-4024
  • Fax: 703-263-1724
Mailing address:
  • Phone: 703-968-4024
  • Fax: 703-263-1724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: