Provider Demographics
NPI:1083180681
Name:MANSUETO, CANDACE RENEA (QBA, LBA, IBA)
Entity type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:RENEA
Last Name:MANSUETO
Suffix:
Gender:F
Credentials:QBA, LBA, IBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2344 PARK GARDEN CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-8675
Mailing Address - Country:US
Mailing Address - Phone:910-644-2326
Mailing Address - Fax:
Practice Address - Street 1:5 DOWD CIR STE A
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-7932
Practice Address - Country:US
Practice Address - Phone:910-644-2326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13744103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst