Healthcare Provider Details

I. General information

NPI: 1154534105
Provider Name (Legal Business Name): MARY CANDELARIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 E INTERCITY AVE STE A
EVERETT WA
98208-2732
US

IV. Provider business mailing address

127 E INTERCITY AVE STE A
EVERETT WA
98208-2732
US

V. Phone/Fax

Practice location:
  • Phone: 425-347-7275
  • Fax: 425-355-0626
Mailing address:
  • Phone: 425-347-7275
  • Fax: 425-355-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2200
License Number StateWA

VIII. Authorized Official

Name: DR. MARY F CANDELARIA
Title or Position: OWNER
Credential: PSYD
Phone: 425-347-7275