Provider Demographics
NPI:1982901153
Name:WIDMER, CANDY L (LMP)
Entity type:Individual
Prefix:
First Name:CANDY
Middle Name:L
Last Name:WIDMER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 N BANNEN RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2273
Mailing Address - Country:US
Mailing Address - Phone:509-892-6936
Mailing Address - Fax:
Practice Address - Street 1:1012 S PERRY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-3465
Practice Address - Country:US
Practice Address - Phone:509-434-9267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60188231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist