Provider Demographics
NPI:1962802058
Name:BERTRAM, CANDISE
Entity type:Individual
Prefix:
First Name:CANDISE
Middle Name:
Last Name:BERTRAM
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 1:17809 MCLEAN RD SW
Mailing Address - Street 2:
Mailing Address - City:VASHON
Mailing Address - State:WA
Mailing Address - Zip Code:98070-5421
Mailing Address - Country:US
Mailing Address - Phone:206-422-2563
Mailing Address - Fax:
Practice Address - Street 1:19330 VASHON HWY SW
Practice Address - Street 2:
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-5212
Practice Address - Country:US
Practice Address - Phone:206-463-4778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60110218225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist