Provider Demographics
NPI:1992140214
Name:BARRY, CANDACE L
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:L
Last Name:BARRY
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:PO BOX 4908
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4908
Mailing Address - Country:US
Mailing Address - Phone:208-237-1711
Mailing Address - Fax:208-237-9806
Practice Address - Street 1:4460 CENTRAL WAY
Practice Address - Street 2:STE 2
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-5095
Practice Address - Country:US
Practice Address - Phone:208-237-1711
Practice Address - Fax:208-237-9806
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health