=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619455847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANDELLA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2018
-----------------------------------------------------
Last Update Date | 11/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427 E KANESVILLE BLVD STE 411
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-268-5503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 225
-----------------------------------------------------
City | ATLANTIC
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50022-0225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-268-5503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CANDELLA FOLEY FINCHEM
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 712-268-5503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 007123
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------