Provider Demographics
NPI:1215502844
Name:SLACK, CANDACE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 GAMBIT DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2526
Mailing Address - Country:US
Mailing Address - Phone:203-213-3474
Mailing Address - Fax:
Practice Address - Street 1:510 NORTH ST STE 10
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4127
Practice Address - Country:US
Practice Address - Phone:413-448-8291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist