Provider Demographics
NPI:1902446057
Name:DELA CRUZ, CANDICE (PT)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:DELA CRUZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SAINT JAMES PL
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-2303
Mailing Address - Country:US
Mailing Address - Phone:678-877-2454
Mailing Address - Fax:
Practice Address - Street 1:103 SAINT JAMES PL
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277-2303
Practice Address - Country:US
Practice Address - Phone:678-877-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT010226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist