=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962025114
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDACE MCKENZIE LMHC L60304682
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2020
-----------------------------------------------------
Last Update Date | 05/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2564 CASCADES PASS BLVD THE LANDINGS BLDG. 779
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-476-8666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1790 SIDNEY AVE APT 3-112
-----------------------------------------------------
City | PORT ORCHARD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98366-2462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-466-8207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | L60304682
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------