Provider Demographics
NPI:1124275938
Name:MAGNUSON, CANDACE LOUISE (LMT)
Entity type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:LOUISE
Last Name:MAGNUSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1872 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3938
Mailing Address - Country:US
Mailing Address - Phone:208-301-2786
Mailing Address - Fax:
Practice Address - Street 1:106 E 3RD ST STE 1C
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2970
Practice Address - Country:US
Practice Address - Phone:208-301-2786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1772225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist