Provider Demographics
NPI:1962875674
Name:BAIN, CANDICE LANELL (MT-BC, PSYD)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:LANELL
Last Name:BAIN
Suffix:
Gender:F
Credentials:MT-BC, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 UNIVERSITY AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-3264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1918 UNIVERSITY AVE STE 2B
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-3264
Practice Address - Country:US
Practice Address - Phone:510-548-9716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA35340103TC0700X
CA12038225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist