Provider Demographics
NPI:1982168647
Name:VAILLETTE, CANDACE MAE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:MAE
Last Name:VAILLETTE
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 1:21163 CONKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93505-2273
Mailing Address - Country:US
Mailing Address - Phone:909-242-1940
Mailing Address - Fax:
Practice Address - Street 1:515 E 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90021-1009
Practice Address - Country:US
Practice Address - Phone:213-529-0963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)