Provider Demographics
NPI:1548301625
Name:VALENTINE, CANDICE MAE (BA)
Entity type:Individual
Prefix:MISS
First Name:CANDICE
Middle Name:MAE
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MRS
Other - First Name:CANDICE
Other - Middle Name:MAE
Other - Last Name:MOLLICA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA
Mailing Address - Street 1:2704 SADDLE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4834
Mailing Address - Country:US
Mailing Address - Phone:631-827-4749
Mailing Address - Fax:
Practice Address - Street 1:2704 SADDLE ROCK RD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4834
Practice Address - Country:US
Practice Address - Phone:631-827-4749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1904828171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor