Provider Demographics
NPI:1215691597
Name:WALLIS, CANDACE NICOLE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:NICOLE
Last Name:WALLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:NICOLE
Other - Last Name:RIEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1600 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2044
Mailing Address - Country:US
Mailing Address - Phone:727-692-7373
Mailing Address - Fax:
Practice Address - Street 1:125 CENTRAL AVE STE 290
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2342
Practice Address - Country:US
Practice Address - Phone:541-267-2113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-24
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL150851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical